Occult Radiographically Evident Port-Site Hernia After Robot-Assisted Urologic Surgery: Incidence and Risk Factors

Pfannenstiel Extraction Site Reduces Postoperative Extraction Site Hernias after Robotic Radical Prostatectomy

Introduction and Objectives: Robotic-assisted radical prostatectomy (RARP) is associated with postoperative hernias at the extraction site, in the inguinal region, and at port sites. We explored hernia rates as well as risk factors for extraction site hernias after RARP based on specimen extraction location in this context. Patients and Methods: We queried a prospectively maintained database of all patients undergoing RARP from November 2006 to June 2023. We collected demographic features, oncologic and pathologic data, 30-day postoperative complications, and postoperative hernia incidence. Specimens were extracted via a midline periumbilical or a Pfannenstiel incision at the conclusion of the case per surgeon preference. Clinically relevant hernias were defined as hernias identified by symptoms or exam findings rather than imaging alone. Univariable and multivariable logistic regressions were used to identify risk factors for postoperative extraction site hernias. Results: In total, 1465 patients underwent radical prostatectomy. Around 23.7% had specimen extraction via Pfannenstiel incision, whereas 76.3% were via extended midline periumbilical port. Patients with a Pfannenstiel extraction had a lower extraction site hernia rate (0.6% vs 7.4%) and clinically significant hernia rate (10.1% vs 14.5%, p = 0.04). On multivariable logistic regression, Hispanic race and Pfannenstiel extraction site were associated with significantly reduced odds of clinically relevant extraction site hernias. Conclusions: Use of a separate Pfannenstiel extraction site is associated with reduced risk of postoperative hernias for patients undergoing RARP. Surgeons should consider extracting the prostate via a Pfannenstiel incision during RARP given this potential benefit.

Incidence of Incisional Hernias after Single-Port Versus Multi-Port Robotic Radical Prostatectomy

Purpose: To determine if single-port robotic-assisted radical prostatectomy (SP-RARP) has higher rates of incisional hernias when compared with multi-port robotic-assisted radical prostatectomies (MP-RARP). Materials and Methods: A retrospective, single-institution review of all consecutive robotic prostatectomy cases between January 2017 and December 2022. Analyzed multi-port and single-port robotic prostatectomies performed by two high-volume surgeons. Measured primary outcome for the development of incisional hernias, as defined by computed tomography imaging and clinical documentation. Multivariable logistic regression was used to determine the effect of the single-port approach on incisional hernia outcomes. Results: A total of 493 patients were included in the study (320 SP-RARPs and 173 MP-RARPs). The overall incisional hernia rate was 8.5% (SP-RARP 8.1% vs MP-RARP 9.2%, p = 0.669). A median follow-up time was 16.6 months and a median time from procedure to hernia diagnosis was 7.4 months. SP-RARP had shorter OR time than the MP-RARP (236 minutes vs 276 minutes, p < 0.001). Patients who developed hernias had higher body mass index (BMIs) than those who did not (30.7 vs 29, p = 0.009). Multivariable logistic regression analysis revealed that patients with higher BMI (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.14) and a history of prior operation (OR 2.23, 95% CI 1.71-4.29) were more likely to develop incisional hernias. Cox regression analysis accounting for the difference in follow-up period demonstrated that SP-RARP 3.4× more likely to develop incisional hernias than MP-RARP (hazard ratio 3.38, 95% CI 1.50-7.58). Conclusions: Patients with higher BMIs and prior history of abdominal surgeries are at increased risk of developing postoperative incisional hernias. SP-RARP procedures confer a higher risk of postoperative incisional hernias.

Evaluation of the Risk Factors for the Incisional Hernia Occurrence After Robot-Assisted Laparoscopic Radical Prostatectomy

Objective: Our aim was to evaluate patient-related factors and compare the techniques used for surgical specimen removal [trocar extension (TE) and Pfannenstiel incision (PF)] in terms of incisional hernia (IH) occurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP). Materials and Methods: The records of 219 patients who underwent RALRP in our clinic between November 2017 and March 2021 were analyzed retrospectively. Postoperative complication data and functional (continence and potency status) and oncological outcomes were recorded. Hernia type, location, and treatments applied were also noted. Results: After exclusion, complete data were available on 192 patients undergoing RALRP between the specified dates. The TE technique for removing the surgical specimen was performed in 135 patients, and the lower abdominal transverse incision technique (PF) in 57 patients. Preoperative patient- and tumor-related characteristics (age, body mass index [BMI], American Society of Anesthesiologists (ASA) score, T stage, and prostate size) were similar in both surgical groups. IH was detected in 16 patients (14 in the TE group and 2 in the PF group) (P = .156). Thirteen patients underwent surgery for IH, and three were followed up clinically. Conclusion: In our study, no statistically significant demographic or surgical technique-related factors were found to explain the occurrence of IH in patients who underwent RALRP for prostate cancer. It was observed that IH occurred more frequently in the cases where the surgical specimen was removed with the TE technique compared with the PF incision, but this result was not statistically significant. There was also no statistically significant difference between these two groups regarding oncological and functional outcomes in the early postoperative period.

Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery

PURPOSE

To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery.

METHODS

We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed.

RESULTS

The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access.

CONCLUSION

The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Natural history of occult hernias in adults at a safety-net hospital

PURPOSE

Occult hernias, hernias seen on radiologic imaging but not felt on physical exam, are common. Despite their high prevalence, little is known about the natural history of this finding. Our aim was to determine and report on the natural history of patients with occult hernias including the impact on abdominal wall quality of life (AW-QOL), need for surgery, and risk of acute incarceration/strangulation.

METHODS

This was a prospective cohort study of patients who underwent a computed tomography (CT) abdomen/pelvis scan from 2016 to 2018. Primary outcome was change in AW-QOL using the modified Activities Assessment Scale (mAAS), a hernia-specific, validated survey (1 = poor, 100 = perfect). Secondary outcomes included elective and emergent hernia repairs.

RESULTS

A total of 131 (65.8%) patients with occult hernias completed follow-up with a median (IQR) of 15.4 (22.5) months. Nearly half of these patients (42.8%) experienced a decrease in their AW-QOL, 26.0% were unchanged, and 31.3% reported improvement. One-fourth of patients (27.5%) underwent abdominal surgery during the study period: 9.9% were abdominal procedures without hernia repair, 16.0% involved elective hernia repairs, and 1.5% were emergent hernia repairs. AW-QOL improved for patients who underwent hernia repair (+ 11.2 ± 39.7, p = 0.043) while those who did not undergo hernia repair experienced no change in AW-QOL (- 3.0 ± 35.1).

CONCLUSION

When untreated, patients with occult hernias on average experience no change in their AW-QOL. However, many patients experience improvement in AW-QOL after hernia repair. Additionally, occult hernias have a small but real risk of incarceration requiring emergent repair. Further research is needed to develop tailored treatment strategies.

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.

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.

Port site hernia at the robotic arm port after robotic-assisted laparoscopic radical prostatectomy

INTRODUCTION

Complications unique to laparoscopic surgery have been reported, including port site hernia. We experienced a case of port site hernia in the robotic right-hand port site measuring 8 mm in diameter after robotic-assisted laparoscopic radical prostatectomy.

CASE PRESENTATION

A 56-year-old man was indicated a high prostate-specific antigen level of 37.8 ng/ml. Subsequent prostate biopsy revealed adenocarcinoma with a Gleason score of 4 + 4. The patient underwent robotic-assisted laparoscopic radical prostatectomy in Juntendo Hospital. Although his postoperative recovery was generally good, the patient complained of sudden nausea and acute abdominal pain. A contrast computed tomography scan showed an ileus due to a hernia occurring at the robotic right-hand port, the da Vinci Arm I port. We released incarceration under laparoscopic procedure.

CONCLUSION

Since the port diameter is relatively small in robot-assisted surgery, port site hernias are expected to be rare. However, careful attention should be paid to the positional deviation of the remote center.

Clinical assessment, radiographic imaging, and patient self-report for abdominal wall hernias

BACKGROUND

Increasingly, abdominal wall hernias are being diagnosed incidentally through radiographic imaging. Such hernias are referred to as occult. However, the clinical significance of occult hernias is unknown. The objective of this study is to determine the prevalence of occult hernias and to assess the abdominal wall quality of life (AW-QOL) among patients with occult hernias.

MATERIALS AND METHODS

A blinded, observational, cross-sectional study, October-December 2016, of patients presenting to single academic institution's general surgery clinics was performed. Inclusion criteria included all patients with a computed tomography scan of the abdomen or pelvis within the last year with no intervening abdominal or pelvic surgery. Patients were administered a validated AW-QOL survey and underwent a standardized clinical examination. Computed tomography scans were reviewed. Primary outcomes were prevalence and AW-QOL measured by the modified Activities Assessment Scale. AW-QOL of patients with no hernias was compared to that of those with occult hernias and clinically apparent hernias using Mann-Whitney U test.

RESULTS

A total of 250 patients were enrolled of whom 97 (38.8%) had a hernia noted on clinical examination and 132 (52.8%) had a hernia noted on radiographic imaging. The prevalence of occult hernias was 38 (15.2%). Patients with no hernia had a median (interquartile range) AW-QOL of 82.5 (55.0-95.3), patients with clinically apparent hernias had AW-QOL of 47.7 (31.2-81.6; P < 0.001), and patients with occult hernias had AW-QOL of 72.4 (38.5-97.2; P = 0.36).

CONCLUSIONS

Both clinically apparent and occult hernias are prevalent. However, only patients with clinically apparent hernias had differences in AW-QOL when compared to patients with no hernias. Prospective trials are needed to assess the outcomes of patients with occult hernias managed with and without surgical repair.

A rare case of acute presentation of trocar site hernia from robot-assisted laparoscopic partial nephrectomy

Trocar site hernia is not a common acute complication encountered after robot-assisted surgery, especially in the urological cohort of patients. A few case reports of small bowel obstruction secondary to incarceration by trocar site hernia have been described in gynaecological surgery and prostatectomies. As the clinical presentation is non-specific, late diagnosis has significant implication on morbidity and mortality. Here, we present a rare case of a patient with recent robot-assisted laparoscopic partial nephrectomy for a renal cell carcinoma presented with features of impending bowel obstruction secondary to incarcerated small bowel in the trocar site. We also reviewed the literature focusing on clinical features of trocar site hernia and preventive measures.

External Validation of the HERNIAscore: An Observational Study

BACKGROUND

The HERNIAscore is a ventral incisional hernia (VIH) risk assessment tool that uses only preoperative variables and predictable intraoperative variables. The aim of this study was to validate and modify, if needed, the HERNIAscore in an external dataset.

STUDY DESIGN

This was a retrospective observational study of all patients undergoing resection for gastrointestinal malignancy from 2011 through 2015 at a safety-net hospital. The primary end point was clinical postoperative VIH. Patients were stratified into low-risk, medium-risk, and high-risk groups based on HERNIAscore. A revised HERNIAscore was calculated with the addition of earlier abdominal operation as a categorical variable. Cox regression of incisional hernia with stratification by risk class was performed. Incidence rates of clinical VIH formation within each risk class were also calculated.

RESULTS

Two hundred and forty-seven patents were enrolled. On Cox regression, in addition to the 3 variables of the HERNIAscore (BMI, COPD, and incision length), earlier abdominal operation was also predictive of VIH. The revised HERNIAscore demonstrated improved predictive accuracy for clinical VIH. Although the original HERNIAscore effectively stratified the risk of an incisional radiographic VIH developing, the revised HERNIAscore provided a statistically significant stratification for both clinical and radiographic VIHs in this patient cohort.

CONCLUSIONS

We have externally validated and improved the HERNIAscore. The revised HERNIAscore uses BMI, incision length, COPD, and earlier abdominal operation to predict risk of postoperative incisional hernia. Future research should assess methods to prevent incisional hernias in moderate-to-high risk patients.

Robotic Single-Port Laparoscopic Cholecystectomy Is Safe but Faces Technical Challenges

BACKGROUND

For cholecystectomy, multiport laparoscopy is the recommended surgical approach. Single-port laparoscopy (SPL) was introduced to reduce postoperative pain and provide better cosmetic results, but has technical disadvantages. Robotic SPL (RSPL) was developed to overcome these disadvantages. In this prospective study, we aim to describe intraoperative results and postoperative outcomes of RSPL cholecystectomies and evaluate technical aspects of the technique.

METHODS

A prospective database of all patients who underwent a RSPL cholecystectomy between January 2012 and December 2014 was analyzed. Intraoperative results and postoperative complications were evaluated.

RESULTS

A total of 27 patients underwent RSPL cholecystectomy. Median age was 59 (20-78) years and median body mass index was 25 (19-35) kg/m². The majority of patients had American Society of Anesthesiologists (ASA) II classification (67%) and 89% underwent surgery for cholecystolithiasis or cholecystitis. The median operating time was 81 (41-115) minutes. Conversion to a multiport procedure occurred in 2; one due to insufficient length of the robotic instruments. In the second and third patients, conversion to an open procedure was necessary due to inadequate exposure caused by liver cirrhosis and purulent ascites, respectively. In seven procedures, spill occurred due to rupture of the gallbladder. Postoperative complications occurred in 4 patients, including 1 bleeding (no reintervention), 1 peritonitis, and 2 wound infections. After a median follow-up of 33 (10-44) months, 5 (19%) trocar-site hernias were seen.

CONCLUSION

RSPL cholecystectomy is feasible, however, encountered by technical challenges due to inadequate length of the nonwristed robotic instruments. A high incidence of gallbladder rupture and trocar-site hernias may limit its application.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.

Herniation formation in women undergoing robotically assisted laparoscopy or laparotomy for endometrial cancer

OBJECTIVE

To compare the incidence of trocar site hernia in women who underwent robotically assisted laparoscopic surgery (RBT) for endometrial cancer staging with the incidence of ventral hernia formation in patients who underwent laparotomy (LAP) for the same indication. To analyze risk factors for hernia formation in women undergoing RBT for endometrial cancer.

METHODS

We retrospectively identified all patients who underwent surgical staging for endometrial cancer via RBT or LAP from 2009-2012. Clinicopathologic data were analyzed. Appropriate statistical tests were used.

RESULTS

738 patients were staged via RBT (n=567) or LAP (n=171). Overall median age was 61 years (RBT range, 33-90; LAP range,28-86; p=0.4). Median BMI was 29.5 kg/m(2) (range, 17.9-66) and 30.3 kg/m(2) (range, 16.8-67.2), respectively (p=1.0). Eleven (1.9%) of 567 patients in the RBT cohort developed a trocar site hernia compared with 11 (6.4%) of 171 LAP patients who developed a ventral hernia (p=0.002). Median time to diagnosis was 18 months (range, 3-49) and 17 months (range, 7-30), respectively (p=0.7). Of the 11 RBT patients who developed a trocar site hernia, 10 (91%) were midline defects and 1 (9%) was a lateral defect of a prior inferior epigastric port site. No hernias required emergent operative intervention. Four (0.7%) of 567 RBT patients compared with 2 (1.2%) of 171 LAP patients required surgical hernia repair (p=0.4).

CONCLUSIONS

Trocar site herniation after RBT staging for endometrial cancer is uncommon and less likely to occur than ventral hernia formation with LAP staging. Furthermore, surgical revision rates are low.