Characteristics of Trocar Site Hernia after Laparoscopic Cholecystectomy

Propensity score-matched comparison of safety outcomes between high-risk and low-risk patients towards early hospital discharge after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC), a common treatment for symptomatic gallstones, has demonstrated safety in low-risk patients. However, existing data are scarce regarding the safety of LC in high-risk patients and the feasibility of early hospital discharge.

Materials and methods

This retrospective study included 2296 patients diagnosed with symptomatic gallstones who underwent LC at a tertiary care centre from January 2009 through December 2019. The authors employed propensity score matching to mitigate bias between groups. Statistical significance was set at P less than 0.05.

Results

The median age of the patients was 56 years (range 46-67), with a mean BMI of 25.2±4.3 kg/m2. Patients were classified as: American Society of Anesthesiologists (ASA) I (19.7%), II (68.3%), III (12.0%), and IV (0%). ASA I-II included low surgical risk patients (88%) and ASA III-IV comprised high-risk patients (12%). The LC-related 30-day reoperative rate was 0.2% and the readmission rate was 0.87%. Nine patients (0.4%) sustained major bile duct injuries, resulting in a conversion rate of 2.4%. The postoperative mortality rate was 0.04%, and the mean hospitalization time was 3.5 days. Patients in the high-risk group with a history of acute cholecystitis exhibited greater estimated blood loss, longer operative times, and were significantly more likely to be in the longer-stay group.

Conclusion

These findings suggest that LC can be conducted safely on high-risk patients, and early hospital discharge is achievable. However, specific factors, such as a history of acute cholecystitis, may result in prolonged hospitalization owing to increased blood loss and longer operative times.

Port Site Obstructed Hernia in a Morbidly Obese Patient: A Case Report

Indications for laparoscopic surgeries are increasing in the current era in view of the advantages they offer in terms of less perioperative morbidities, early mobilization, and better cosmesis. These benefits are perceived even more in obese women. However, there are special challenges in this population, associated with their body habitus, poor visibility, and perioperative anesthesia risks. Difficulty in port closure is one such problem encountered in these women causing inadequate rectus suturing and leading to port site hernia. We report a case of a 59-year-old morbidly obese lady who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection for carcinoma endometrium. The intraoperative course was uneventful. In the postoperative period, she developed acute obstruction due to port site herniation of the small bowel, which was not suspected till postoperative day five. This was due to an inaccurate assessment of her abdomen because of her body habitus. A CT scan was done in view of the non-resolving obstruction, which revealed herniation of a small bowel loop through the umbilical port. Immediate correction was resorted to under local anesthesia. Rectus sheath closure was done in the same sitting. The patient had a quick recovery after that and was discharged three days later. Rectus sheath closure should be done for all ports 10 mm or greater in diameter. There should be a low threshold to get cross-sectional imaging in postoperative obese women with non-resolving gastrointestinal symptoms.

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.

Drain-site hernia after laparoscopic rectal resection: A case report and review of literature

BACKGROUND

Drain-site hernia (DSH) has an extremely low morbidity and has rarely been reported. Small bowel obstruction is a frequent concurrent condition in most cases of DSH, which commonly occurs at the ≥ 10 mm drain-site. Here we report a rare case of DSH at the lateral 5 mm port site one month postoperatively without visceral incarceration. Simultaneously, a brief review of the literature was conducted focusing on the risk factors, diagnosis, and prevention strategies for DSH.

CASE SUMMARY

A 76-year-old male patient was admitted to our institution with intermittent abdominal pain and a local abdominal mass which occurred one month after laparoscopic radical resection of rectal cancer one year ago. A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant, and that the content consisted of the large omentum. An elective herniorrhaphy was performed by closing the fascial defect and reinforcing the abdominal wall with a synthetic mesh simultaneously. The postoperative period was uneventful. The patient was discharged seven days after the operation without surgery-related complications at the 1-mo follow-up visit.

CONCLUSION

Emphasis should be placed on DSH despite the decreased use of intra-abdominal drainage. It is recommended that placement of a surgical drainage tube at the ≥ 10 mm trocar site should be avoided. Moreover, it is advisable to have a comprehensive understanding of the risk factors for DSH and complete closure of the fascial defect at the drainage site for high-risk patients.

Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration

OBJECTIVES

The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload.

METHODS

A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group.

RESULTS

A total of 683 patients (14.5%) had a mean BMI of 39.9 (35-63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates.

CONCLUSIONS

This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Umbilical port versus epigastric port for gallbladder extraction in laparoscopic cholecystectomy: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

After laparoscopic cholecystectomy, gallbladder can be extracted either from epigastric/subxiphoid port or umbilical port. We conducted systematic review of randomized controlled trials comparing the two.

METHODS

PRISMA-compliant systematic review and meta-analysis was conducted with pre-specified study protocol registered on PROSPERO (CRD42019128662). Multiple databases were searched from inception till 14 September 2019 using search terms "gallbladder", "specimen", "extraction', "extract", "cholecystectomy", "epigastric port", "subxiphoid port" "umbilical port". Outcomes assessed were postoperative pain (visual analog scale at 24 h postoperatively), port-site hernia, port-site infection, operative time and gallbladder retrieval time. Data were analyzed using random-effects models with risk ratios (RR) for dichotomous variables and mean difference (MD) for continuous variables.

RESULTS

Of 280 articles retrieved, 9 RCT's with 1036 participants were included. Quality of included studies was judged to be "moderate" to "low". There was no difference in postoperative pain at 24 h (p = 0.76), total operative time (p = 0.11), gallbladder retrieval time (p = 0.72) or surgical site infection (p = 0.93). Umbilical port retrieval was associated with significantly higher risk of port-site herniae (RR 2.68, 95%CI:1.06-6.80, p = 0.04). After sensitivity analysis, operative time was significantly shorter with epigastric retrieval (p = 0.0007). Trial sequential analysis showed that current studies were successful in achieving optimum information size for primary outcome.

CONCLUSIONS

There was no difference in postoperative pain and infections between umbilical and epigastric port retrieval. Umbilical port retrieval was associated with significantly higher risk of developing port-site hernia and could also be associated with longer operative time. Epigastric port may be favorable for gallbladder retrieval in multiport laparoscopic cholecystectomy.

Trocar-Related Safety Events in Minimally Invasive Surgical Procedures: Risks for Organ and Vascular Complications

A trocar is a hollow device used during minimally invasive surgery that serves as an entry port for optical scopes and surgical equipment. Insertion of this device into the body is determined using anatomical landmarks taking into consideration the patient’s history and physical attributes, e.g., scars or abdominal size. Insertion of the first trocar is the time of highest risk of injury. Intestinal and vascular injuries are two potentially life-threatening injuries that can occur. A retrospective review of trocar-related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between January 1, 2014, and June 30, 2020, identified 268 events. Internal organ and vascular injuries accounted for 81.0% of events; trocar site skin integrity injuries, bleeding/hemorrhage, and hernias accounted for 17.2% of events; and vasovagal responses accounted for 1.9% of events. Internal injuries occurring during the initial insertion of the trocar, Veress needle, or incision in preparation for a trocar insertion was reported in 64.5% of events. Adhesions were identified in 13.5% of internal injury events. Many internal injury events identified a single injury; however, in 17 instances patients sustained two trocar-related injuries. Conversion to open surgery, return to the operating room during the same admission, postoperative intensive care unit admission, ambulatory surgical facility transfer to a hospital, readmission, postdischarge return to the operating room, and death are outcomes identified in the event reports.

A simple and reliable procedure for laparoscopic port-site closure

PURPOSE

One of the complications in laparoscopic surgery is port-site hernia. It is a rare but potentially dangerous complication. Especially when using ports with a size 10 mm or more, it is required to securely close the port site. However, this procedure is often difficult especially for obese patients.

METHODS

We herein devised a new closure method by using a device developed for port site. These techniques are methods that can close the port site by a combination of putting in and out of thread and port rotation without removing a port. The port-site closure with these techniques was done for 53 port sites of 41 patients.

RESULTS

The port site was closed horizontally or vertically, depending on the shape of the port site for two patients. Modified Z-suture was done for other 37 patients. To date, we have not noted any complications from this new method, including port-site hernia.

CONCLUSION

With our technique, we could save operation time and reduce stress of us especially for obese patients. We would like to increase the number of patients and verify the safety and usefulness in further study.

Special type trocar-site hernia with evisceration of the appendix following laparoscopic repair of a perforated duodenal ulcer

Trocar-site hernia is an uncommon complication of laparoscopic surgery and can be classified as early-onset, late-onset or special type. Special type hernias usually occur in the early postoperative period and result in evisceration of intra-abdominal contents through all layers of the abdominal wall without an overlying hernia sac. We present a case of special type herniation of the appendix through a 5-mm trocar site in the right iliac fossa following laparoscopic repair of a perforated duodenal ulcer. In this case, herniation occurred after removal of a drain inserted through the trocar site intraoperatively and was treated with emergent open appendicectomy. A number of patient and technical factors may be associated with an increased risk of trocar-site herniation including increasing age, elevated body mass index, increasing trocar size, longer procedure duration and absence of fascial closure. These factors must be borne in mind when planning trocar placement and number to reduce the risk of herniation.

Needlescopic surgery for large umbilical hernia in a patient with morbid obesity using intraperitoneal onlay mesh with fascial defect closure: a case report

Background

The European and American guidelines recommend that symptomatic umbilical hernias (UHs) are repaired using an open approach with a preperitoneal flat mesh. However, the standard treatment procedure for large UH in patients with extreme obesity is yet to be established. Here, we present the first case of a patient with morbid obesity undergoing laparoscopic UH repair using needlescopic instruments and an intraperitoneal onlay mesh plus repair (IPOM plus).

Case presentation

A 29-year-old man, who was classified as morbidly obese (body mass index, 36.7 kg/m²) noticed a reducible nontender mass in the umbilical region and was subsequently diagnosed with an UH, with a diameter of 4 cm. Laparoscopic IPOM plus repair was planned using a needlescopic method for a large UH in the patient with morbid obesity. A 3-mm rigid laparoscope was mainly used in the procedure. After a 12-mm trocar and two 3-mm trocars were inserted, fascial defect closure was performed using intracorporeal suturing with 0 monofilament polypropylene threads. Then, IPOM was performed laparoscopically using an 11.4-cm round mesh coated with collagen to prevent adhesions. The operative time and blood loss were 57 min and 1 g, respectively. The postoperative course was uneventful.

Conclusions

Reduced-port laparoscopic surgery using needlescopic instruments and an IPOM plus technique is a minimally invasive and convenient combination option for large UH in a patient with morbid obesity.

Incidence and risk factors for umbilical trocar site hernia after laparoscopic TAPP repair. A single high-volume center experience

BACKGROUND

Trocar site hernia (TSH) is often underestimated after minimally invasive surgery. Scarce information is available about the incidence of TSH in patients undergoing laparoscopic hernioplasty. We aimed to evaluate the incidence and risk factors of umbilical TSH after laparoscopic TAPP hernioplasty in patients with and without an associated umbilical hernia.

METHODS

A retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic inguinal TAPP repair during 2013-2018 was performed. After TAPP repair, the umbilical fascia was closed either by a figure-of-eight stitch with absorbable suture (G1) or by umbilical hernioplasty if it was present (G2). Multivariate logistic regression analysis was used to determine the TSH risk factors. Comparative evaluation regarding demographics, and operative and postoperative variables was performed.

RESULTS

A total of 535 laparoscopic TAPP repairs were included. There were 359 (67.1%) patients in G1 and 176 in G2 (32.9%). Surgical site infection was higher in G2 (G1: 0.6% vs G2: 5.7%, p = 0.001). Overall TSH rate was 3.9% after a mean follow-up of 20 (12-41) months. Performing a concomitant umbilical repair significantly increased the risk of umbilical TSH (G1: 2.2% vs G2: 7.4%, p = 0.004). TSH rates in G2 were similar in patients with simple suture or mesh repairs (p = 0.88). Rectus abdominis diastasis (OR 37.8, 95% CI:8.22-174.0, p < 0.001) and inguinal recurrence (OR 13.5, 95% CI:2.04-89.5, p = 0.007) were independent risk factors for TSH.

CONCLUSION

Although trocar site hernia after laparoscopic TAPP repair has a low incidence, its risk is significantly increased in patients with a concomitant umbilical hernia repair, rectus abdominis diastasis, and/or inguinal recurrence.

Evaluation of a Novel Trocar-Site Closure Device in Laparoscopic Surgery

Background and Objectives:

We evaluated the effectiveness and safety of EZ-Close^TM compared to those of hand suture for trocar-site closure according to obesity.

Methods:

Fifty-four cases of laparoscopic colorectal surgery were enrolled. For the same patient, the right port site was closed using EZ-Close^TM and left port site was closed by hand suture among cases with port-site diameter ≥10 mm. Cases switched to use of a conventional fascial closure device or with closure time 120 s were considered failures. Closure time was analyzed according to body mass index (BMI) and abdominal wall thickness (AWT).

Results:

The mean closure time was significantly shorter with EZ-Close^TM than with hand suture (87.9 ± 21.0 vs. 128.0 ± 59.0 s, p < 0.001). The number of failure cases was significantly lower with EZ-Close^TM than with hand suture (7 vs. 27, p < 0.001). The closure time of EZ-Close^TM was significantly shorter than that of hand suture in patients with BMI ≥ 25 and < 27 kg/m² (n = 15, 85.9 ± 19.8 vs. 135.6 ± 67.9 s, p < 0.014) and ≥ 27 kg/m² (n = 13, 85.1 ± 18.4 vs. 150.2 ± 70.6 s, p < 0.010). With respect to AWT, the closure time of EZ-Close^TM was significantly shorter than that of hand suture in patients with AWT ≥ 20 and < 26 mm (n = 12, 81.1 ± 11.5 vs. 142.3 ± 83.7 s, p = 0.023) and ≥ 26 mm (n = 17, 85.6 ± 22.6 vs. 160.2 ± 55.5, p < 0.001). No infection and herniation were detected in both trocar sites during the follow-up period (median 20.4 months).

Conclusion:

EZ-Close^TM could provide time efficiency in trocar-site closure, especially in obese patients.