Trocar Site Hernias in Bariatric Surgery-an Underestimated Issue: a Qualitative Systematic Review and Meta-Analysis

Assessment of the effectiveness of a polypropylene onlay mesh in the prevention of laparoscopic trocar-site incisional hernia in high-risk patients. A randomized clinical trial

PURPOSE

Trocar site incisional hernia (TSIH) is a common complication of laparoscopic surgery. In the scientific literature there are few descriptions of methods or tools for its prevention. The aim of this report was to assess the effectiveness and safety of a prophylactic measure designed to lower rates of TSIH.

METHODS

A multicenter randomized double-blinded clinical trial was performed in high-risk patients (diabetes mellitus and/or age ≥ 70 years and/or BMI ≥ 30 kg/m2 and/or extended incision for specimen retrieval) who underwent either elective or emergency laparoscopic cholecystectomy. Patients were assigned to prophylactic onlay polypropylene mesh fixation (intervention) or to standard trocar closure (control). The main aim was to analyze the efficacy of the intervention, taking occurrence of TSIH as the primary outcome. Clinical and radiological follow up lasted at least one year after surgery. Secondary endpoints were technique-related complications (surgical site occurrences).

RESULTS

One hundred and forty-three patients were randomized and finally 116 were analyzed (64 in the intervention arm and 52 in the control arm). Groups were homogeneous. Mean [SD] age, 65 [18] years; 86 (60.6%) were women. The cumulative TSIH incidence was lower in the intervention group although the differences did not reach statistical significance, assessed either radiologically (16 [25.4%] vs 17 [31.5%], p = 0.538) or clinically (9 [16.1%] vs 9 [20], p = 0.613). No differences in surgical site infection, hematoma or seroma were detected. Mean follow-up was 670 days (range 223-1294).

CONCLUSION

Our results show that, when properly assessed, the overall TSIH incidence is extremely high. Although polypropylene onlay mesh placement is safe, it does not appear to be effective in reducing the TSIH incidence rate. Radiological evaluation may be more accurate.

TRIAL REGISTRATION

ClinicalTrials.org NCT03495557. Date of registration: April 12, 2018.

Sarcopenia and body fat change as risk factors for radiologic incisional hernia following robotic nephrectomy

OBJECTIVE

To assess the effect of body muscle and fat metrics on the development of radiologic incisional hernia (IH) following robotic nephrectomy.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent robotic nephrectomy for kidney tumors between 2011 and 2017. All pre- and postoperative CTs were re-reviewed by experienced radiologists for detection of radiologic IH and calculation of the following metrics using Synapse 3D software: cross-sectional psoas muscle mass at the level of L3 and L4 as well as subcutaneous and visceral fat areas. Sarcopenia was defined as psoas muscle index below the lowest quartile. Cox proportional hazard model was constructed to examine the association between muscle and fat metrics and the risk of developing radiologic IH.

RESULTS

A total of 236 patients with a median (IQR) age of 64 (54-70) years were included in this study. In a median (IQR) follow-up of 23 (14-38) months, 62 (26%) patients developed radiologic IH. On Cox proportional hazard model, we were unable to detect an association between sarcopenia and risk of IH development. In terms of subcutaneous fat change from pre-op, both lower and higher values were associated with IH development (HR (95% CI) 2.1 (1.2-3.4), p = 0.01 and 2.4 (1.4-4.1), p < 0.01 for < Q1 and ≥ Q3, respectively). Similar trend was found for visceral fat area changes from pre-op with a HR of 2.8 for < Q1 and 1.8 for ≥ Q3.

CONCLUSION

Both excessive body fat gain and loss are associated with development of radiologic IH in patients undergoing robotic nephrectomy.

Not deep enough: Modeling the effect of shallow placement of the DaVinci Xi "bariatric" long trocar on the muscular abdominal wall

INTRODUCTION

The DaVinci Xi Robotic Surgical System (Xi) long cannula (Intuitive Surgical Company, Sunnyvale, CA) provides five additional centimeters of distal length compared to the standard Xi trocar. The extra length allows the cannula to traverse prohibitively thick body wall tissue. Our aims are to quantitatively model the consequences of not preserving the rotational centerpoint of motion (RCM) at the muscular abdominal wall. This is an essential tenet in robotic surgery; it is violated with shallow placement of the long trocar. This leads to unchecked, unnoticed blunt widening of port sites by the robotic arm, increasing hernia risk.

METHODS

We begin with an exploration of the schematic of the Xi robotic arm as patented by Intuitive (U.S. Patent #5931832). We trigonometrically model the lateral displacement of the abdominal wall at the trocar site with respect to vertical trocar shallowness, instrument tip depth, and instrument tip lateral motion from neutral midline.

RESULTS

The rigid parallelogram movement structure of the Xi preserves the RCM at the thick black marker printed on every Xi cannula. By limitation of design, both long and standard trocars must have this marker at the exact same distance from their proximal end. The value ranges of our model parameters (presuming a reasonable maximum orientation angle of 45° from midline) are: trocar shallowness [1 cm, 7 cm]; instrument tip depth [0 cm, 20 cm]; instrument tip lateral movement [0.0 cm, 14.1 cm]. Abdominal wall displacement increased proportionally as each instrument tip parameter reached its maximum deviation from the orthogonal midline as described in the plot figure. Maximal wall displacement at maximal shallowness was approximately 7.0 cm.

CONCLUSION

Robotic surgery revolutionizes modern operation, particularly within bariatrics. However, the current Xi arm design disallows a true long trocar to be used safely without compromising the RCM, thereby risking hernia development.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

Management of High Output Enterocutaneous Fistula due to Richter's Hernia After Gastric Bypass: Video Demonstration

INTRODUCTION

The increase in laparoscopic surgery in patients with obesity increases the incidence of trocar site hernia (TSH). Therefore, TSH represents a risk for the development of Richter's hernia (RH).

METHODS

We present the unusual case of a postoperative gastric bypass patient complicated with a high output enterocutaneous fistula through a trocar site wound.

RESULTS

The Laparoscopic surgery consists of an RH reduction, enterotomy, and repair of the preperitoneal space.

CONCLUSION

RH complicated by high-output enterocutaneous fistula has not been previously reported. It is essential to close the preperitoneal space in bariatric surgery to avoid these complications.

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.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies

BACKGROUND

Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia.

METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative.

RESULTS

Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised.

CONCLUSION

These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

Safety and Efficacy of Trocar Port-Site Closure Using a Biological Plug Closure in Laparoscopic Bariatric Surgery: a Prospective Study

PURPOSE

Port-site trocar closure is a challenging procedure in laparoscopic surgeries, especially in morbidly obese patients, and complications (herniation, bleeding, pain, and nerve trapping) have potentially severe consequences. This paper provides an overview of existing techniques of suturing and closure in intra-abdominal laparoscopic surgery, outlines the complications associated with port-site closure, and presents a novel technique designed to address those problems by using a sterile absorbable gelatin sponge with strong hemostatic properties (Cutanplast® Plug).

MATERIALS AND METHODS

In this prospective study, 83 successive obese patients undergoing laparoscopic bariatric surgery (sleeve gastrectomy, sleeve plication, gastric bypass), using a standardized skin incision for trocar insertion, had port-site closure using the Cutanplast plug procedure (n = 42) or conventional suturing techniques (n = 41).

RESULTS

The incidence of early complications was lower in the Cutanplast group; no patients had infections compared with 9.8% of Controls (p = 0.055) and no bleeding, ecchymosis, erythema, or redness occurred. Late complications during 2 years of follow-up were significantly lower in the Cutanplast group (0 vs. 7 hernias, p = 0.005). Most patients in the Cutanplast group required only 1-2 procedures (78.6% vs. 58.5%, p = 0.049), whereas 41.5% of controls required 3 procedures. In total, 82 trocars were used in the Cutanplast group versus 99 in controls. The single-step Cutanplast plug technique reduced operating times compared with two-step suturing techniques.

CONCLUSION

Closure of port-site trocar incisions using Cutanplast plug is fast, efficient, with potential to reduce operating times and decrease bleeding and herniation from port-site trocars insertion, particularly in obese patients.

Prevention of incisional hernia after single-port sleeve gastrectomy (PRISM): a prospective non-randomized controlled study

BACKGROUND

SPSG carries a risk of incisional hernia, particularly in patients with high body mass index. Prophylactic mesh placement with either permanent or absorbable mesh could decrease the occurrence of incisional hernia, with uncertainty on other postoperative parietal complications.

METHODS

This is a non-randomized monocentric single-blinded prospective study. High-risk patients (body mass index ≥ 45 kg/m²) underwent either 3 strategies of parietal closure (suture with or without permanent or absorbable mesh) during SPSG. The primary outcome was the occurrence of radiologically defined incisional hernia during the first postoperative year. Secondary outcomes included surgical site infection rates and postoperative pain.

RESULTS

Between November 2018 and November 2019, 255 patients were included (85 in each group). All patients reached one-year postoperative follow-up. Significantly more incisional hernias were observed in the no mesh group in comparison with permanent and absorbable mesh groups, respectively (20% vs. 7.1% vs. 5.1%, P = 0.005). No difference was observed in mesh groups. No difference was observed regarding other parietal complications. One patient in the absorbable mesh group presented a superficial surgical site infection and required surgical drainage without mesh removal and one patient in the permanent mesh group presented a parietal hematoma and required surgical drainage with mesh removal. Twenty-six (92.8%) asymptomatic patients presented incisional hernia discovered on the one-year CT-scan.

CONCLUSIONS

Prophylactic mesh placement during SPSG decreases the occurrence of postoperative incisional hernia. Routine permanent mesh placement could be proposed in high-risk patients.

An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure

PURPOSE

To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest.

METHODS

Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity.

RESULTS

Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I² 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I² 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I² 58% and 0.04 (95% CI 0.03-0.06), I² 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I² 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I² 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24).

CONCLUSION

Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.

Trocar site hernia after gastric sleeve

BACKGROUND

Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position was found to be a reliable method for the detection of TSH following gastric bypass (LRYGB). In the present study, our aim was to examine the incidence of TSH after gastric sleeve, and further to investigate the proportion of symptomatic trocar site hernias.

METHODS

Seventy-nine patients subjected to laparoscopic gastric sleeve in 2011-2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey.

RESULTS

The incidence of trocar site hernia was 17 out of 79 (21.5%), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no significant correlation between patient symptoms and a TSH.

CONCLUSIONS

The incidence of TSH is high after laparoscopic gastric sleeve, a finding in line with several recent studies as well as with our first trial on trocar site hernia after LRYGB. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of a trocar site hernia can be serious, the proportion of symptomatic TSH needs to be more clarified.

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

Importance

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.

Objective

This article aims to provide a summary of the available literature concerning port-site hernia and explore preventive strategies for future clinical practice.

Evidence Acquisition

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.

Results

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.

Conclusions

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.

Relevance

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.

"What Really Matters When Performing a Laparoscopic Roux-en Y Gastric Bypass?" Literature-Based Key Steps Towards Success and Standardization of the Procedure

Lack of standardization in the Roux-en-Y gastric bypass (RY-GBP) is quite well established. We all learned the basics of the technique, but a lot of differences do exist in performing each step of the procedure. Based on scientific evidences, coming from an extensive and meticulous review of the literature of the last 20 years, we thus address the different technical steps of the procedure and their importance to try and propose a standardization of RYGBP. A lot of possibilities exist at each and every step of a RYGBP. They influence the postoperative complications, the end weight loss (EWL), weight regain, and resolution of obesity bounded comorbidities. Furthermore, lack of standardization leads to problems regarding comparison of scientific data in the related literature.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.

Sutureless energy-based wound closure: a step in the quest for trocar site hernia prevention

OBJECTIVE

Easy and safe methods of fascia closure are needed in order to reduce the risk for trocar site hernias without affecting procedure time significantly. Here we present a method for port site closure using heat induced collagen denaturation.

MATERIAL AND METHODS

Controlled heat-induced collagen denaturation was applied to laparoscopic trocar sites in living porcine animal models. These were compared to control trocar sites which were left open. Port sites were evaluated visually at days 14 and 28 after the procedure, and both visually and pathologically at post-procedural day 42.

RESULTS

A total of 12 port sites were evaluated in three pigs. No incisional hernias were noted at any of the trocar sites in both groups. Histological evaluation revealed that one of the six control ports appeared to have a complete transfascial defect, whereas none of the study group trocars showed this finding. Furthermore, the study port sites showed a more robust scarring pattern.

CONCLUSIONS

Heat-induced collagen denaturation in this preliminary study was found to be safe and allowed better scarring of the healing port sites. We believe that this technology may offer a safe and efficient closure of laparoscopic trocar sites. More studies are needed to further evaluate the true effectiveness of this technology.Abbreviations: TSH: trocar site hernia; IACUC: institutional animal care and use committee.

Randomized control trial on effectiveness and safety of direct trocar versus Veress needle entry techniques in obese women during diagnostic laparoscopy

PURPOSE

To determine the benefits and safety of direct trocar insertion versus Veress needle technique in obese women undertaking diagnostic laparoscopy procedures.

METHODS

Randomized-controlled trial on 135 obese women undergoing diagnostic laparoscopy and dye test for infertility was conducted. Women were randomly assigned to either direct trocar access (n = 68) or Veress needle access (n = 67) before achieving pneumoperitoneum. The same surgeon executed the laparoscopic techniques with a single-puncture technique. The primary outcome measures included total length of the procedure and incidence of any complications, while the mean laparoscopic entry time, volume of CO₂ required, and total of tries needed to attain successful entry were secondary outcomes. Intention-to-treat principle was applied to analysis.

RESULTS

Women in both groups had similar socio-demographic and clinical characteristics and none were lost to follow-up. The overall length of the procedure was significantly lesser in the direct trocar group compared to the Veress needle group (9.9 ± 6.0 vs 16.7 ± 4.7 min; p < 0.001). No significant differences occurred in other outcomes including mean entry time, volume of CO₂ used, number of attempts for successful entry, and major/minor complications (p > 0.05).

CONCLUSIONS

Direct trocar technique may be an effective alternative to Veress needle for pneumoperitoneum in obese women for diagnostic laparoscopy. It has a comparable rapid laparoscopic entry time but a significantly lower duration of the procedure and shorter exposure to anesthesia. Both methods are equally effective as there was no significant difference in the complications recorded. A greater sample trial may be essential for more corroborative substantiation.

CLINICAL TRIAL REGISTRATION

PACTR201510000999192.

Omental evisceration in a gravid woman following second-trimester laparoscopy: A case report

Surgeons performing laparoscopy in pregnancy are developing specific practices to improve care of gravid women. In this case, a pregnant 26-year-old patient underwent laparoscopic ovarian cystectomy in the second trimester, with cyst wall removal through an 8 mm umbilical port site incision. She returned four days later with pain and drainage from the umbilicus, and examination under anesthesia revealed omental evisceration through the umbilical incision. The patient healed well following excision of affected omentum, reapproximation of fascia in a simple, interrupted fashion, and closure of skin in a subcuticular fashion. Due to increased intra-abdominal pressure associated with a gravid uterus and other factors, port site closure for incisions smaller than 10 mm may improve healing and prevent complications of laparoscopic surgery in pregnancy.

Asymptomatic trocar site hernias: An underestimated complication of laparoscopy

Objective

To estimate the exact incidence of trocar site hernia (TSH) through sonographic examination and to evaluate the predisposing risk factors of TSH.

Materials and Methods

Three hundred patients who underwent laparoscopic surgery for benign gynecologic indications were included in this study and called back for a follow-up visit. All patients underwent an ultrasound evaluation for the detection of TSH. Risk factors for TSH formation were investigated.

Results

Twenty-five (8.3%) TSHs were diagnosed among 300 postoperative laparoscopies. The highest rate of TSH development among the surgeries was found in tubal ligation cases with 19%. Parity ≥3 [odds ratio (OR), 3.13; 95% confidence interval (CI): 1.21-8.09; p=0.018], and not closing fascia (OR: 6.74; 95% CI: 2.72-16.70; p<0.001) were statistically significant risk factors for the development of TSH in multivariate analysis.

Conclusion

The prevalence of TSH is higher than previously reported, and ultrasonographic examination is adequate for detecting subclinical types of this complication.

Trocar-site hernia after gynecological laparoscopic surgery: a 20-year, single-center experience

Background:

Trocar-site hernia (TSH) is a serious complication after laparoscopic procedures. Although it is a rare entity, it can have life-threatening consequences. This study aimed to retrospectively analyze the potential associated factors for TSH following gynecologic laparoscopy and summarize prevention strategies based on our experience.

Methods:

We searched for gynecological laparoscopic surgeries in the medical records system of Peking Union Medical College Hospital (PUMCH) from August 1998 to July 2018 and further sifted through the results for cases involving TSH. All included patients were divided into different groups according to patient characteristics, and the rate of TSH was compared among groups. Moreover, the detailed information of all patients with TSH was recorded and analyzed. Statistical analyses were performed with GraphPad Prism 6.

Results:

The approximate total rate of post-operative TSH among gynecologic laparoscopy procedures performed at PUMCH in the last 20 years was 0.016% (9/55,244). The rate of TSH was significant higher in elder patients (≥60 years old; 3/2686, 0.112%) than in younger patients (<60 years old, 6/52,558; 0.011%, P = 0.008). Moreover, the approximate rate of TSH was significantly higher after single-incision laparoscopic surgery (SILS, 2/534, 0.357%) than conventional laparoscopic surgery (7/54,710, 0.013%, P = 0.003). The average age of patients with TSH was 53.4 years (range, 35.0–79.0 years). Two of the nine patients had late-onset TSH following SILS; the other seven had early-onset TSH following conventional laparoscopy. Five TSH cases occurred at right lateral port sites, and the remaining three occurred at the umbilical port site. All patients underwent repair surgery, and one required small bowel resection.

Conclusion:

Older age and SILS are potential associated factors for TSH development, while reducing excessive manipulation and improving suturing skills, especially at the umbilical trocar site following SILS and the right lateral trocar site, can avoid herniation.