Port-site hernia following laparoscopic cholecystectomy

Port-site hernia recurrence at previous 5-mm laparoscopic access: case report and review of literature

Port-site hernia (PSH) of less than 10 mm is an exceptionally rare complication of minimally invasive surgery (MIS). To date, there have been no cases in the literature reporting recurrence of PSH from a 5 mm incision. We present the first case of PSH recurrence in a woman who underwent surgery for benign gynaecological pathology via a MIS approach. Her post-operative course was complicated by an episode of symptomatic hernia arising from a 5 mm accessory trocar which was surgically managed. A few months later she re-presented with the same symptoms and had a PSH recurrence of the same port-site. Two corrective surgeries employing different techniques were performed. The first episode was managed laparoscopically using interrupted stitches. On the other hand, the PSH recurrence was managed by placement of a mesh. Ultrasound played a crucial role in diagnostics, especially in the recurrent setting. Due to the complete absence of similar cases in the literature, the decision making around the management of a PSH recurrence from a 5 mm trocar site proved to be challenging. As MIS is the current standard of care, more cases are likely to occur, however despite the increasing number of surgical procedures performed via MIS, no established guidelines for managing such complications have been proposed. Trying to bridge this gap, we present the case report of the first case of PSH recurrence from a 5 mm accessory port and a review of the most significant literature available to date. We finally summarise the reported cases of PSH and the types of surgical repair conducted to highlight the absence of a standard of care.

Insights Into Laparoscopic Port Site Complications: A Comprehensive Review

Laparoscopic surgery has become a widely accepted standard of care for numerous procedures in the modern world. Nearly every major surgical procedure previously only possible by employing open techniques may now be completed laparoscopically, attributable to the quick advancement of technology and surgeons' abilities. There are several complications associated with the laparoscopic port site, either infective, non-infective, or neoplastic. This study aims to explore the morbidity associated with the port site following laparoscopic surgery and discuss the risk factors for complications. The umbilical port was most frequently associated with port-site hernia (PSH), followed by the epigastrium and the left and right hypochondrium. Prolonged port manipulation and reinsertion, longer surgical times, failure to effectively close the fascial defect, and wound infection are responsible for the development of PSH. Port-site infection (PSI) is one avoidable adverse effect of laparoscopic surgery. Patients who have a history of diabetes, malnourishment, prolonged preoperative hospital stays, preoperative Staphylococcus aureus colonization of the nares, perioperative blood transfusions, and tobacco or steroid use are more likely to have PSI. Port-site hydatid cyst (PSHC) and port-site tuberculosis (PST) are rare but possible. While uncommon, a doctor should rule out endometriosis if a painful mass in the surgical scar, such as the trocar site, is discovered in a reproductive-age woman who has had pelvic or obstetric surgery in the past. Port-site metastasis (PSM) is the term for tumor-cell implantation at the trocar insertion site after a malignant tumor is removed laparoscopically. PSM has been reported in 1-2% of laparoscopic gynecologic surgical procedures. A few potential mechanisms for cell implantation at the port site include embolization of exfoliated cells during tumor dissection or hematogenous spread, air turbulence during long laparoscopic operations, and direct implantation onto the wound during forced, unprotected organ/tissue retrieval or from contaminated surgical instruments during tumor dissection. Nonetheless, the triggering mechanism is likely essentially multifaceted. Prevention is better than cure. Port-site hernia can be prevented using smaller trocars and meticulous rectus sheath defect closure at the end of surgery. The rest of the port site complications can be prevented by employing autoclavable laparoscopic hand instruments, utilizing autoclaved water to clean the instruments following disassembly, adhering to the recommended concentration, contact duration, and usage cycles when sterilizing instruments with liquid sterilizers, preventing bile or gut content from spilling into the operating room or the port site, using non-porous specimen retrieval bags for recovering the specimen, and thoroughly cleaning and irrigating the port site before closing the wound.

Transumbilical laparoscopy for pneumoperitoneum establishment: a comprehensive multicentre evaluation affirming safety, feasibility, and a range of clinical benefits

Introduction

Transumbilical laparoscopy (TUL) has emerged as a promising technique for establishing pneumoperitoneum in laparoscopic cholecystectomy, offering potential safety, feasibility, and clinical benefits. This retrospective multicentre study aims to evaluate the efficacy and outcomes of TUL in the management of gallbladder diseases.

Methods

A retrospective analysis was conducted on a cohort of 2,543 patients who underwent TUL between 2011 and 2021 across various medical institutions in Italy. Data collection included demographic, clinical, intraoperative, and postoperative parameters. Standardized protocols were followed for preoperative and postoperative management. The TUL technique involved precise anatomical incision and trocar placement.

Results

The study demonstrated favorable outcomes associated with TUL, including a low conversion rate to open surgery (0.55%), minimal intraoperative complications (0.16%), and short hospital stays (average 2.4 days). The incidence of incisional hernias was notably low (0.4%). Comparison with existing literature revealed consistent findings and provided unique insights into the advantages of TUL.

Discussion

Despite limitations, such as the absence of a control group and the retrospective nature of the study, the findings contribute valuable insights to the literature. They inform surgical decision-making and advance patient care in laparoscopic cholecystectomy for gallbladder diseases.

Conclusion

Transumbilical laparoscopy shows promise as a safe and feasible technique for establishing pneumoperitoneum in laparoscopic cholecystectomy. The study's findings support its clinical benefits, including low conversion rates, minimal complications, and short hospital stays. Further research, including prospective studies with control groups, is warranted to validate these results and optimize patient outcomes.

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.

Machine Learning Analysis of Postlaparoscopy Hernias and "I'm Leaving You to Close" Strategy

INTRODUCTION

Contributing factors to postlaparoscopy hernia are unknown. We hypothesized that postlaparoscopy incisional hernias are increased when the index surgery was performed in teaching hospitals. Laparoscopic cholecystectomy was chosen as the archetype for open umbilical access.

MATERIALS AND METHODS

Maryland and Florida SID/SASD databases (2016-2019) wereused to track 1-year hernia incidence in both inpatient and outpatient settings, which was then linked to Hospital Compare, Distressed Communities Index (DCI), and ACGME. Postoperative umbilical/incisional hernia following laparoscopic cholecystectomy was identified using CPT and ICD-10. Propensity matching and eight machine learning modes were utilized including logistic regression, neural network, gradient boosting machine, random forest, gradient boosted trees, classification and regression trees, k nearest neighbors and support vector machines.

RESULTS

Postoperative hernia incidence was 0.2% (total = 286; 261 incisional and 25 umbilical) in 117,570 laparoscopic cholecystectomy cases. Days to presentation (mean ± SD) were incisional 141 ± 92 and umbilical 66 ± 74. Logistic regression performed best (AUC 0.75 (95% ci 0.67-0.82) and accuracy 0.68 (95% ci 0.60-0.75) using 10-fold cross validation) in propensity matched groups (1:1; n = 279). Postoperative malnutrition (OR 3.5), hospital DCI of comfortable, mid-tier, at risk or distressed (OR 2.2 to 3.5), LOS >1 d (OR 2.2), postop asthma (OR 2.1), hospital mortality below national average (OR 2.0) and emergency admission (OR 1.7) were associated with increased hernias. A decreased incidence was associated with patient location of small metropolitan areas with <1 million residents (OR 0.5) and Charlson Comorbidity Index-Severe (OR 0.5). Teaching hospitals were not associated with postoperative hernia after laparoscopic cholecystectomy.

CONCLUSIONS

Different patient factors as well as underlying hospital factors are associated with postlaparoscopy hernias. Performance of laparoscopic cholecystectomy at teaching hospitals is not associated with increased postoperative hernias.

Hernia Formation: Risk Factors and Biology

The incidence of ventral hernias in the United States is in increasing. Herein, the author details the etiology of congenital and acquired ventral hernias as well as the risk factors associated with the development of each of these types of ventral hernias.

Parietex™ Composite Ventral Patch for primary and incisional hernia repair

BACKGROUNDS

Ventral hernia repair with a preformed device is a frequent intervention, but few reports exist with Parietex™ Composite Ventral Patch. The aim was to evaluate the results of this mesh with the open intraperitoneal onlay mesh (open IPOM) technique.

METHODS

Observational retrospective single institution study of all consecutive patients intervened for ventral or incisional hernia with a diameter inferior to 4 cm, from January 2013 to June 2020. The surgical repair was performed according to the open IPOM technique with Parietex™ Composite Ventral Patch.

RESULTS

A total of 146 patients were intervened: 61.6% with umbilical hernias, 8.2% with epigastric hernias, 26.7% with trocar incisional hernias, and 3.4% with other incisional hernias. The global recurrence rate was 7.5% (11/146). Specifically, it was 7.8% in umbilical hernias, 0% in epigastric hernias, 7.7% in trocar incisional hernias and 20% (1/5) in other incisional hernias. The median time for recurrence was 14 months (IQR: 4.4-18.7). The median indirect follow-up was 36.9 months (IQR: 27.2-49.6), and the median presential follow-up was 17.4 months (IQR: 6.5-27.3).

CONCLUSION

The open IPOM technique with a preformed patch offered satisfactory results for the treatment of ventral and incisional hernias.

Vermiform Appendix within Post-Laparoscopic Incisional Hernia: A Unique Case Report and Literature Review

Background: Appendicitis within incisional hernia is an extraordinarily rare postoperative complication with an incidence range from 0.08 to 1%. From the 14 cases that we found in the English literature, only three present appendixes vermiform in incisional hernia followed by laparoscopic surgery. Only two cases are treated minimally invasively by the laparoscopic approach. Case presentation: We introduce a 65-year-old man who had a laparoscopic sigmoid colon resection and had a lump found at the 12 mm trocar site in the right iliac area in the late postoperative phase. There were no complaints from the patient. A vermiform appendix was unexpectedly discovered in the sac of that incisional hernia during control CT scans performed by chemotherapists. Laparoscopic hernia repair without appendectomy was performed. Postoperative outcomes were excellent. Conclusions: Because of low incidence and a lack of distinctive clinical presentation of appendicitis within incisional hernia, there is a risk of delayed perioperative diagnosis and treatment. A CT scan might play an important role in verifying the diagnosis early. For better postoperative outcomes, if possible, laparoscopic surgery should be chosen.

An Observational Study Comparing Hybrid Transvaginal Notes and Four-Port Laparoscopic Cholecystectomy

BACKGROUND

Recently, a great interest has arisen in hybrid natural orifice transluminal endoscopic surgery-cholecystectomy (NOTES-C). It has the potential to cause less postoperative pain and may offer better cosmesis over conventional laparoscopic cholecystectomy (CLC).

PATIENTS AND METHODS

A total of 112 females who underwent conventional cholecystectomy were compared with 108 patients of hybrid transvaginal NOTES-cholecystectomy (TV NOTES-C). We compared intraoperative factors, postoperative pain, the analgesic requirement at different intervals, duration of hospital stay, and time to return to normal activities. In addition, cosmesis and patient satisfaction were assessed at four weeks.

RESULTS

Postoperative pain and analgesic requirement were less in the hybrid TV NOTES-C group (p<0.001 at 95% CI). Hybrid TV NOTES-C patients were discharged more frequently within 12 hours (27.5% versus 1.8%; p<0.001) and returned faster (2.22 versus 4.62 days; p<0.001) to normal activities. Cosmetic results and short-term quality of life as assessed by the patient and observer scar assessment scale (POSAS) and short form-36 (SF-36) scores, respectively, were better in the hybrid TV NOTES-C group (p<0.001 at 95% CI).

CONCLUSIONS

Hybrid TV NOTES-C is associated with reduced postoperative analgesic requirements, faster return to normal activities, better cosmesis, and patient satisfaction compared to conventional four-port cholecystectomy.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review

Background

In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min.

Case presentation

A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence.

Conclusions

The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01528-6.

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.

Long-term follow-up of the incisional hernia rate after single-incision laparoscopic cholecystectomy: a prospective observational study

PURPOSE

To evaluate the long-term occurrence rate of incisional hernias following single-incision laparoscopic cholecystectomy (SILC).

BACKGROUND

Since the 90 s, SILC has emerged as a less invasive alternative to standard laparoscopic cholecystectomy in selected patients. But concerns over port-incisional hernias have not been addressed.

METHODS

Between February 2009 and February 2011, 142 patients referred for gallstones who agreed to undergo SILC were included in a monocenter prospective observational study. All of the procedures were carried out using a single-port access technique. The occurrence rates of incisional hernias were analyzed with the Kaplan-Meier actuarial method. Statistical significance was set at p < .05.

RESULTS

A total of 142 patients with gallbladder pathology were included in the study; 138 of them underwent SILC and 4 were converted to standard multiport cholecystectomy. Twelve patients (8%) were found to have developed a port-site incisional hernia (PSH) by physical examination or by imaging. The Kaplan-Meier curve showed that the rate of PSH development was 83% in the first 2 years after surgery. After 2 years, this risk becomes quite low.

CONCLUSIONS

Our results indicate that the SILC procedure is a safe option for treatment of benign gallbladder diseases for selected patients, albeit with a high incisional hernia rate.

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.

Risk factors of incisional hernia after single-incision cholecystectomy and safety of barbed suture material for wound closurewound closure

Purpose

Single-incision cholecystectomy is a surgical method that offers comparable results to conventional laparoscopic cholecystectomy. However, a high risk of postoperative incisional hernia is an issue in single-incision cholecystectomy. This study evaluated the risk factors and incidences of incisional hernia after single-incision cholecystectomy and the advantage issue of using barbed suture material during wound closures.

Methods

A total of 1,111 patients underwent laparoscopic or robotic single-incision cholecystectomy between March 2014 and February 2020 at our institution at CHA Bundang Medical Center. During this period, there were 693 patients who underwent wound closure with monofilament suture material (Monosyn 2-0; B. Braun) and the other 418 patients used barbed suture material (Stratafix 2-0; Ethicon).

Results

The two patient groups were comparable in age, body mass index, and diagnosis. The total incidence of incisional hernia after single-incision cholecystectomy was 0.5% (five cases). All patients who developed incisional hernia were in the monofilament suture material group (0.7% vs. 0%, p = 0.021). The influence of predictive and possible risk factors on incisional hernia rate was analyzed. Among these factors, only old age was an independent predictive risk factor of incisional hernia.

Conclusion

Our study showed a low incidence of incisional hernia, all of which occurred in the monofilament suture material group. If technically appropriate, single-incision cholecystectomy does not appear to present a high incidence of hernia. Barbed suture material can be safely applied in wound closure showing comparable incisional hernia incidence to monofilament suture material.

Review of imaging in post-laparoscopy cholecystectomy complications

Laparoscopic cholecystectomy is now considered the procedure of choice for uncomplicated symptomatic gallstone disease worldwide. Various biliary, vascular, gastrointestinal, neurological and local complications may be seen on imaging post surgery. Knowledge of these entities and imaging appearances is indispensable for the radiologist in today's era. We emphasize on the list of potential complications and imaging appearances of this surgical procedure.

Colecistectomía segura: ¿Qué es y cómo hacerla? ¿Cómo lo hacemos nosotros?

La colecistectomía laparoscópica es uno de los procedimientos más realizados a nivel mundial. La técnica laparoscópica se considera el estándar de oro para la resolución de la patología de la vesícula biliar secundaria a litiasis, y aunque es un procedimiento seguro, no se encuentra exenta de complicaciones. La complicación más grave es la lesión de la vía biliar, que, aunque es poco frecuente, con una incidencia de 0,2 a 0,4%, conduce a una disminución en la calidad de vida y contribuye a un aumento en la morbi-mortalidad. El objetivo de este artículo es reportar nuestra técnica quirúrgica, enfatizando los principios del programa de cultura para una colecistectomía segura, propuesta y descrita por the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), para minimizar los riesgos y obtener un resultado quirúrgico satisfactorio.

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.

A safe and reliable technique for fascial closure without special devices after laparoscopic surgery

INTRODUCTION

To prevent port-site hernia, we established a simple and low-cost closure method that uses a venous catheter needle and suture, without any other special devices.

MATERIALS AND SURGICAL TECHNIQUE

We used the inner needle of a 16-G venous catheter and a 2-0 absorbable bladed suture. To evaluate the efficacy of this technique, the procedure time was noted and compared among three operators (an experienced surgeon and two inexperienced surgeons).

DISCUSSION

The median suturing time was 60.5 seconds (range, 26-130 seconds) per incision. Even an unexperienced surgeon can close the fascia safely and quickly after some experience with the procedure.

Incisional hernias following gallstone surgery. A population-based study

BACKGROUND

The aim of this study was to determine the incidence of incisional hernia (IH) in a population-based cohort following gallstone surgery and to identify associated risk factors.

METHODS

All cholecystectomies registered in the Swedish register for cholecystectomy and ERCP from 2006 to 2014 were identified. Data regarding post-procedural development of IH was obtained from the National Patient Register.

RESULTS

A total of 81 964 cholecystectomies were identified. A laparoscopic, open, and minilaparotomy technique was used in 70 031, 10 379 and 1554 procedures, respectively. The five-year cumulative incidence of IH was 1.04 per cent in the laparoscopic group, 3.37 per cent in the open group, and 2.11 per cent in the minilaparotomy group. Obesity (hazard ratio (HR) 4.11, 95 per cent confidence interval [CI] 3.37 to 5.01), open surgical technique (HR 2.97, CI 2.57 to 3.42), liver cirrhosis (HR 2.95, CI 1.58 to 5.51), chronic kidney disease (HR 1.95, CI 1.19 to 3.21), minilaparotomy (HR 1.79, CI 1.23 to 2.60), age > median (HR 1.43, CI 1.25 to 1.65), and chronic pulmonary disease (HR 1.28, CI 1.05 to 1.57) were found to significantly predict the development of IH.

CONCLUSION

Laparoscopic cholecystectomy comes with a lower risk of IH compared to open techniques.

Randomized controlled trial of single incision versus conventional multiport laparoscopic cholecystectomy with long-term follow-up

Background

Within the last years, single-incision laparoscopic cholecystectomy (SLC) emerged as an alternative to multiport laparoscopic cholecystectomy (MLC). SLC has advantages in cosmetic results, and postoperative pain seems lower. Overall complications are comparable between SLC and MLC. However, long-term results of randomized trials are lacking, notably to answer questions about incisional hernia rates, long-term cosmetic impact and chronic pain.

Methods

A randomized trial of SLC versus MLC with a total of 193 patients between December 2009 and June 2011 was performed. The primary endpoint was postoperative pain on the first day after surgery. Secondary endpoints were conversion rate, operative time, intraoperative and postoperative morbidity, technical feasibility and hospital stay. A long-term follow-up after surgery was added.

Results

Ninety-eight patients (50.8%) underwent SLC, and 95 patients (49.2%) had MLC. Pain on the first postoperative day showed no difference between the operative procedures (SLC vs. MLC, 3.4 ± 1.8 vs. 3.7 ± 1.9, respectively; p = 0.317). No significant differences were observed in operating time or the overall rate of postoperative complications (4.1% vs. 3.2%; p = 0.731). SLC exhibited better cosmetic results in the short term. In the long term, after a mean of 70.4 months, there were no differences in incisional hernia rate, cosmetic results or pain at the incision between the two groups.

Conclusions

Taking into account a follow-up rate of 68%, the early postoperative advantages of SLC in relation to cosmetic appearance and pain did not persist in the long term. In the present trial, there was no difference in incisional hernia rates between SLC and MLC, but the sample size is too small for a final conclusion regarding hernia rates.

Trial registration

German Registry of Clinical Trials DRKS00012447

Dual-hemostat port closure technique with customized surgical suture after laparoscopic cholecystectomy: Single-center experience

INTRODUCTION

Dual-hemostat techniques for port closure have previously been reported, but their safety and efficacy have not been evaluated. Here, we describe the dual-hemostat port closure technique employed at our institution, which uses a customized surgical suture for safe and certain port closure, and we assess the incidence rate of trocar-site hernia (TSH) after laparoscopic cholecystectomy.

METHODS

From March 1999 to March 2017 at our institution, 316 patients underwent elective laparoscopic cholecystectomy performed by a single experienced surgeon. We routinely used a dual-hemostat technique with a customized surgical suture to achieve safe and certain port closure. We assessed the incidence rate of TSH after laparoscopic cholecystectomy (defined as a reoperation for a TSH or clinical hernia at the port site) based on follow-up data from patient questionnaires and clinical examinations.

RESULTS

After 67 patients were excluded because of death, unknown address, or conversion to open cholecystectomy, 249 eligible patients received questionnaires, of which 173 were returned (response rate, 69.5%). From these responses, TSH was suspected in three patients, but only one underwent reoperation for TSH after laparoscopic cholecystectomy. Thus, the incidence rate of TSH after laparoscopic cholecystectomy was 0.6% (1/173).

CONCLUSIONS

Our single-center experience demonstrated that our port closure technique using a dual-hemostat technique with customized surgical suture provides an appropriate option for laparoscopic cholecystectomy, especially given its ease and low incidence of TSH.

Incidence and Risk Factors of Incisional Hernia After Single-Incision Endoscopic Surgery

Introduction: Abdominal wall complications are one of the most controversial issues regarding single-incision endoscopic surgery. The aim of this study was to analyze the incidence and risk factors of incisional hernia after single-incision endoscopic cholecystectomy. Materials and Methods: An observational retrospective study was performed, on a cohort of patients cholecystectomized laparoscopically through a transumbilical single incision due to gallbladder lithiasis or polyps. Postoperative complications were analyzed, with special interest in the incisional hernia rate, whose results were assessed in the long-term follow-up. Univariate and multivariate analyses were also performed to evaluate possible variables associated with the appearance of incisional hernia. Cumulative sum charts (CUSUM) were used to identify trends in the incisional hernia risk. Results: Some 109 patients were included in the study. With a mean follow-up of nearly 38 months, an incisional hernia incidence of 5.5% was found, with 67% being diagnosed during the first year of follow-up. In the Cox regression analysis, two variables showed an independent association with the emergence of incisional hernia, body mass index (hazard ratio [HR] 1.30; 95% confidence interval [CI 1.053-1.606]; P .015), and wound infection (HR 26.32; [3.186-217.40]; P .002]. CUSUM charts showed a decrease in the risk of incisional hernia after the first 10 cases. Conclusions: Single-incision endoscopic cholecystectomy is associated with a substantially high risk of postoperative incisional hernia (5.5%).

Single-Port Versus Conventional Laparoscopic Cholecystectomy: Better Cosmesis at the Price of an Increased Incisional Hernia Rate?

Background: The incidence of trocar site hernia (TSH) in single-port laparoscopic cholecystectomy (SPC) is still a debated issue. Aim of this retrospective study was to compare the incidence of postoperative hernia and cosmetic results among patients undergoing SPC and multiport laparoscopic cholecystectomy (MPC) performed at a single institution. Methods: A series of 60 SPC and 60 MPC patients operated on between July 2016 and May 2018 were compared. Primary endpoint was to assess the incidence of TSH at long term. All the patients were admitted as outpatients for physical examination and scar measurement. Secondary endpoints were the cosmetic results assessed by a cosmesis score (CS) and the body image questionnaire (BIQ). Results: After a median 18-month follow-up (range: 6-29 months), a hernia in umbilical trocar site was detected in 4 (7.1%) SPC patients and 1 (2%) MPC patient, the difference not being statistically significant (P = .216). BIQ was almost equivalent in SPC and MPC groups (5.15 versus 5.27; P = .518), respectively. Statistically significant differences in favor of SPC were found in CS (22.3 versus 19.72; P = .001) and in total length of scars (1.2 cm versus 4 cm; P < .001). Conclusions: SPC technique has proved to be safe and effective in experienced hands. Superior cosmesis of SPC over MPC is confirmed, but close attention to fascial closure is a vital component of SPC, and surgeons performing single-site surgery need to be aware of this increased potential for hernia formation.

Long-term follow-up after single-incision laparoscopic surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) is growing in popularity. The increased diameter of the umbilical incision might raise questions about the possibility of a greater risk of postoperative incisional hernia in comparison to conventional laparoscopy. This study aims to disclose the frequency of incisional hernia after SILS in long-term follow-up as well as to reveal the factors predisposing patients to this feared complication.

METHODS

The patient collective consists of cholecystectomy and appendectomy patients, who were operated on using SILS technique. Follow-up was achieved through letter correspondence, telephone interview, and clinical examination. Effects of demographic variables and operative parameters including age, sex, BMI, ASA score, duration of surgery, pre-existing hernia as well as postoperative incidence of incisional hernia were investigated using univariate and multivariate analyses.

RESULTS

A total of 286 cases with complete follow-up were included in the analyses. Mean follow-up duration was 58.4 months. 192 patients (67.1%) underwent cholecystectomy; 94 (32.9%) had an appendectomy. The study collective consisted of 218 women (76.2%) and 68 men (23.8%). Mean age at the date of the operation was 38.5 (median 36, range 13-74). In 5 cases (1.7%), the surgical approach was converted into conventional laparoscopy. Intraoperative complication rate was 0.3% and postoperative complication rate was 5.9%. 7 patients (2.4%) developed an incisional hernia. Obese patients had an incisional hernia incidence of 10.9%. 3 out of 19 patients (15.8%) with a pre-existing umbilical hernia developed an incisional hernia during follow-up. Obesity and pre-existing umbilical hernia proved to have a significant association with incisional hernia incidence in univariate and multivariate analyses. Sex, age, procedure (appendectomy vs cholecystectomy), presence of acute inflammation, and duration of surgery did not show a statistically significant association with incisional hernia.

CONCLUSION

Detection of incisional hernia necessitates a long follow-up duration. Obesity and pre-existing umbilical hernia are associated with a higher incidence of this complication. Following a careful patient selection, SILS offers a safe approach for cholecystectomy and appendectomy procedures.

Is the 8-mm robotic port safe? A case of trocar site hernia after robotic cholecystectomy using the da Vinci Xi system

With the increase in the frequency of robotic surgery, complications have also increased, including trocar site hernias, which rarely occur at the 8-mm port site after robotic cholecystectomy using the da Vinci Xi system. A 37-year-old woman was diagnosed with cholecystitis on abdominal sonography. She underwent robotic cholecystectomy using a bikini-line incision. However, after postoperative day 2, she presented to the emergency room with small bowel obstruction secondary to a herniated bowel loop through the left 8-mm port site. After failure to resolve the ileus, the patient underwent emergency surgery, and bowel resection and anastomosis of the ischemic area were performed. After surgery, the patient was discharged without complications. Although hernias develop less commonly at 8-mm robotic port sites, surgeons should carefully close the ports, especially in cases with large fascial defects or a high risk of herniation.

First 100 consecutive robotic inguinal hernia repairs at a Veterans Affairs hospital

The utilization of robotics in general surgery has increased significantly including usage in the Veterans Affairs (VA) system. We implemented a robotic inguinal hernia repair (RIHR) program in our VA hospital and report on initial experience with safety and outcomes. The first 100 consecutive RIHR at a VA hospital were reviewed and compared against the results of contemporaneous open inguinal hernia repair (OIHR). Data were collected for operative characteristics, surgical complications and pain related outcomes. Overall, operative times for OIHR were less than RIHR (83.7 vs. 109.7 min, p < 0.0001); however, there was no difference in operative time for bilateral repairs (121.5 vs. 121.9 min, p = ns). Complication rates were similar between the groups. RIHR patients had less pain at POD 1 than OIHR patients (p = 0.05). RIHR were less likely to have multiple post-op visits for pain than OIHR patients (p = 0.003). RIHR can be implemented in the VA system with acceptable surgical outcomes. RIHR may be associated with less post-operative pain in the early post-operative period.

Incisional hernia prevention and use of mesh. A narrative review

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

Port insertion for minimally invasive surgery: a report of practices in the Irish Republic

BACKGROUND

With rapidly evolving surgical technologies, minimally invasive surgery (MIS) has become the mainstay approach for many surgeons worldwide. As laparoscopic surgery was introduced in Ireland over two decades ago, we may be encountering a higher prevalence of related complications.

AIMS

This study aimed to gather data pertaining to risk factors for port-site herniation in MIS.

METHODS

A 14-point anonymous questionnaire was distributed electronically between January and May 2017 to consultant and trainee laparoscopists in the Republic of Ireland. This survey related to laparoscopic volume and surgical approaches to laparoscopic port-sites.

RESULTS

There were 172 eligible responses nationally. Approaches to peritoneal access included Hasson, veress (blind puncture) and SILS were 66.3, 32.6 and 1.2%, respectively. Senior surgeons and specialists in Obstetrics and Gynaecology (OBGYN) reported significantly higher utilisations of closed peritoneal access (p < 0.05). Of the participants, 119 (69.2%) reported using a bladeless trocar over a bladed type. Fascial closure was utilised in 94.2% of ≥ 10 mm and 2.3% of 5-mm ports using absorbable suture in 76.7%, non-absorbable suture in 14.5% and port closure devices in 8.7%. Perceptions of risk factors for PSH were not congruent with significant variations in responses between levels of expertise.

CONCLUSIONS

This study demonstrates significant variations in laparoscopic port-site practices amongst surgeons nationally. The new era of practitioners may benefit from evidence-based technical workshops and guidelines to increase awareness and reduce potential complications.

Bowel injury following gynecological laparoscopic surgery

Background

Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication.

Methods

We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment.

Results

Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed.

Conclusion

Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.

Trocar site hernia following laparoscopic cholecystectomy: a 10-year single center experience

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard of treatment for patients with symptomatic cholelithiasis. Compared to open cholecystectomy, LC is associated with significantly lower postoperative complications. Trocar site hernia (TSH) is an uncommon, but potentially dangerous, complication of LC. The aim of this study was to evaluate the incidence of TSH following LC.

METHODS

The records of all patients who underwent elective LC between January 2004 and December 2013 were retrospectively reviewed. The open technique with a vertical incision infraumbilically was used to establish pneumoperitoneum. Two or three other skin incisions were made and trocars were inserted. In all cases, only the fascia at the site of infra-umbilical incision was closed. Following hospital discharge, all patients were regularly re-examined 1, 4 and 52 weeks postoperatively and were contacted by phone during November-December 2015. Based on the findings from clinical and telephone follow-ups, the incidence of TSH was recorded. Using univariate/multivariate analysis, we investigated several variables to identify risk factors for TSH development.

RESULTS

During the study period, 1172 patients were eligible and included in the final analysis. Seven patients (0.6%) presented TSH at 1-year follow-up. At the end of the study and with a mean follow-up of 65.86 ± 25.19 months, 11 patients (0.94%) presented TSH. Interestingly, all TSHs were developed at the infra-umbilical site. Multivariate analysis identified obesity as an independent risk factor for TSH.

CONCLUSION

The incidence of TSH following LC is considerably low. Obesity is an independent risk factor for TSH development, while closure of fascial incision of 10 mm below the xiphoid is not justified.

A Comparative Study of Outcomes Between Single-Site Robotic and Multi-port Laparoscopic Cholecystectomy: An Experience from a Tertiary Care Center

BACKGROUND

The aim of this study was to compare the outcomes of single-site robotic cholecystectomy with multi-port laparoscopic cholecystectomy within a high-volume tertiary health care center.

METHODS

A retrospective analysis of prospectively maintained data was conducted on patients undergoing single-site robotic cholecystectomy or multi-port laparoscopic cholecystectomy between October 2011 and July 2014. A single surgeon performed all the surgeries included in the study.

RESULTS

A total of 678 cholecystectomies were performed. Of these, 415 (61%) were single-site robotic cholecystectomies and 263 (39%) were multi-port laparoscopic cholecystectomies. Laparoscopic patients had a greater mean BMI (30.5 vs. 29.0 kg/m²; p = 0.008), were more likely to have undergone prior abdominal surgery (83.3 vs. 41.4%; p < 0.001) and had a higher incidence of preexisting comorbidities (76.1 vs. 67.2%; p = 0.014) as compared to the robotic group. There was no statistical difference in the total operative time, rate of conversion to open procedure and mean length of follow-up between the two groups. The mean length of hospital stay was shorter for patients within the robotic group (1.9 vs. 2.4 days; p = 0.012). Single-site robotic cholecystectomy was associated with a higher rate of wound infection (3.9 vs. 1.1%; p = 0.037) and incisional hernia (6.5 vs. 1.9%; p = 0.006).

CONCLUSION

Multi-port laparoscopic cholecystectomy should remain the gold standard therapy for gallbladder disease. Single-site robotic cholecystectomy is an effective alternative procedure for uncomplicated benign gallbladder disease in properly selected patients. This must be carefully balanced against a high rate of surgical site infection and incisional hernia, and patients should be informed of these risks.

Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis

BACKGROUND

The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC).

METHODS

A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia.

RESULTS

Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups.

CONCLUSION

SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.

Incisional hernia after robotic single-site cholecystectomy: a pilot study

PURPOSE

Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci^® Single-Site^®) with the da Vinci^® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique.

METHODS

In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected.

RESULTS

We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m² [±SD 4.1 kg/m²]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients.

CONCLUSION

This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.

Complications of Laparoscopic Cholecystectomy: Our Experience from a Retrospective Analysis

AIM:

The aim of this study was to evaluate the intraoperative and postoperative complications of laparoscopic cholecystectomy, as well as the frequency of conversions.

MATERIAL AND METHODS:

Medical records of 740 patients who had laparoscopic cholecystectomy were analysed retrospectively. We evaluated patients for the presence of potential risk factors that could predict the development of complications such as age, gender, body mass index, white blood cell count and C-reactive protein (CRP), gallbladder ultrasonographic findings, and pathohistological analysis of removed gallbladders. The correlation between these risk factors was also analysed.

RESULTS:

There were 97 (13.1%) intraoperative complications (IOC). Iatrogenic perforations of a gallbladder were the most common complication - 39 patients (5.27%). Among the postoperative complications (POC), the most common ones were bleeding from abdominal cavity 27 (3.64%), biliary duct leaks 14 (1.89%), and infection of the surgical wound 7 patients (0.94%). There were 29 conversions (3.91%). The presence of more than one complication was more common in males (OR = 2.95, CI 95%, 1.42-4.23, p < 0.001). An especially high incidence of complications was noted in patients with elevated white blood cell count (OR = 3.98, CI 95% 1.68-16.92, p < 0.01), and CRP (OR = 2.42, CI 95% 1.23-12.54, p < 0.01). The increased incidence of complications was noted in patients with ultrasonographic finding of gallbladder empyema and increased thickness of the gallbladder wall > 3 mm (OR = 4.63, CI 95% 1.56-17.33, p < 0.001), as well as in patients with acute cholecystitis that was confirmed by pathohistological analysis (OR = 1.75, CI 95% 2.39-16.46, p < 0.001).

CONCLUSION:

Adopting laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay. It is important recognising IOC complications during the surgery so they are taken care of in a timely manner during the surgical intervention. Conversion should not be considered a complication.

Incisional hernia in pediatric surgery - experience at a single UK tertiary centre

AIMS

Incisional hernia (IH) is a recognized complication of open and laparoscopic visceral surgery, with reported rates of 10-50% in adult surgical literature. There is a paucity of data relating to incisional hernias in children. The aim of our study was to analyze the incidence and treatment of IH in children.

METHODS

Retrospective review of all patients admitted for incisional hernia repair at a tertiary pediatric surgical centre in the UK more than a 7-year period was performed. Data collected included age at initial surgery, time to IH repair, and type of IH repair and postoperative complications.

RESULTS

Twenty one patients (14 male) underwent IH repair during the study period. The incidence of IH among children who had primary abdominal surgery in our institution less than the age of 6months was 2.3%. Median age at repair was 7.9months (range: 18days-5years). Median time from primary surgery to diagnosis of IH was 2months (range 0day-3years), with 81% (17/21) diagnosed within 1year of the preceding abdominal procedure. The most common pathology necessitating the primary operative procedure was necrotising enterocolitis (n=9) in babies of gestational age less than 30weeks. The highest rates of IH were noted in infants following closure of stoma (7.5%) and pyloromyotomy (2.52%). Primary closure was undertaken in all cases. Two children had recurrence of IH, one of which underwent surgical repair.

CONCLUSIONS

Incidence of IH in children is low but significant. IH was most commonly diagnosed following closure of stoma for NEC in this study.

The Earliest Presenting Umbilical Port Site Hernia Following Laparoscopic Cholecystectomy: A Case Report

Port site hernia after laparoscopic surgery is a rare complication. Here we present a case of a 55-year-old female, diagnosed with an anterior abdominal wall hernia through the 10mm umbilical port, just two days after her laparoscopic cholecystectomy. The uniqueness of this case is its extremely early presentation. Patient presented with features of acute intestinal obstruction and due to prompt diagnosis and timely intervention, she underwent a successful reduction of hernia and an anatomical repair of the fascial and peritoneal defect through the midline laparotomy incision.

Laparoscopic access overview: Is there a safest entry method?

BACKGROUND

Laparoscopy is a minimally invasive technique to access the abdominal cavity, for diagnostic or therapeutic applications. Optimizing the access technique is an important step for laparoscopic procedures. The aim of this study is to assess the outcomes of different laparoscopic access techniques and to identify the safest one.

METHODS

Laparoscopic access questionnaire was forwarded via e-mail to the 60 centers who are partners in working group for laparoscopic and robotic surgery of the Italian Urological Society (SIU) and their American and European reference centers.

RESULTS

The response rate was 68.33%. The total number of procedures considered was 65.636. 61.5% of surgeons use Veress needle to create pneumoperitoneum. Blind trocar technique is the most commonly used, but has the greatest number of complications. Optical trocar technique seems to be the safest, but it's the less commonly used. The 28,2% of surgeons adopt open Hasson's technique. Total intra-operative complications rate was 3.3%. Open conversion rate was 0.33%, transfusion rate was 1.13%, and total post-operative complication rate was 2.53%.

CONCLUSION

Laparoscopic access is a safe technique with low complication rate. Most of complications can be managed conservatively or laparoscopically. The choice of access technique can affect the rate and type of complications and should be planned according to surgeon experience, safety of each technique and patient characteristics. All access types have perioperative complications. According with our study, optical trocar technique seems to be the safest.

Use of a multi-instrument access device in abdominoperineal resections

BACKGROUND

Laparoscopic colorectal surgery results in less post-operative pain, faster recovery, shorter length of stay and reduced morbidity compared with open procedures. Less or minimally invasive techniques have been developed to further minimise surgical trauma and to decrease the size and number of incisions. This study describes the safety and feasibility of using an umbilical multi-instrument access (MIA) port (Olympus TriPort+) device with the placement of just one 12-mm suprapubic trocar in laparoscopic (double-port) abdominoperineal resections (APRs) in rectal cancer patients.

PATIENTS AND METHODS

The study included 20 patients undergoing double-port APRs for rectal cancer between June 2011 and August 2013. Preoperative data were gathered in a prospective database, and post-operative data were collected retrospectively.

RESULTS

The 20 patients (30% female) had a median age of 67 years (range 46-80 years), and their median body mass index (BMI) was 26 kg/m2 (range 20-31 kg/m2). An additional third trocar was placed in 2 patients. No laparoscopic procedures were converted to an open procedure. Median operating time was 195 min (range 115-306 min). A radical resection (R0 resection) was achieved in all patients, with a median of 14 lymph nodes harvested. Median length of stay was 8 days (range 5-43 days).

CONCLUSION

Laparoscopic APR using a MIA trocar is a feasible and safe procedure. A MIA port might be of benefit as an extra option in the toolbox of the laparoscopic surgeon to further minimise surgical trauma.

Incidence of port-site incisional hernia after single-incision laparoscopic surgery

Background and Objectives:

Single-incision laparoscopic surgery is gaining popularity among minimally invasive surgeons and is now being applied to a broad number of surgical procedures. Although this technique uses only 1 port, the diameter of the incision is larger than in standard laparoscopic surgery. The long-term incidence of port-site hernias after single-incision laparoscopic surgery has yet to be determined.

Methods:

All patients who underwent a single-incision laparoscopic surgical procedure from May 2008 through May 2009 were included in the study. Single-incision laparoscopic surgical operations were performed either by a multiport technique or with a 3-trocar single-incision laparoscopic surgery port. The patients were seen at 30 to 36 months' follow-up, at which time they were examined for any evidence of port-site incisional hernia. Patients found to have hernias on clinical examination underwent repairs with mesh.

Results:

A total of 211 patients met the criteria for inclusion in the study. The types of operations included were cholecystectomy, appendectomy, sleeve gastrectomy, gastric banding, Nissen fundoplication, colectomy, and gastrojejunostomy. We found a port-site hernia rate of 2.9% at 30 to 36 months' follow-up.

Conclusion:

Port-site incisional hernia after single-incision laparoscopic surgical procedures remains a major setback for patients. The true incidence remains largely unknown because most patients are asymptomatic and therefore do not seek surgical aid.

Incisional hernia after single-incision laparoscopic cholecystectomy: incidence and predictive factors

AIM

To access the incidence and predictive factors of incisional hernia after single-incision laparoscopic cholecystectomy (SILC).

METHODS

Eighty-two consecutive patients operated on for uncomplicated cholelithiasis between 2009 and 2013 were eligible for the study. Clinical outcome was assessed by a combination of case notes review, office consultation and telephone interview. Long-term incisional hernia rate was the major outcome of the study. Secondary outcome was the evaluation of predictive factors. Univariate and multivariate statistical analyses were performed using the following variables: age, gender, ASA score, BMI, risk, or comorbidity factors and surgical site infection.

RESULTS

Six patients (7 %) were lost to follow-up after the 1-month office visit and excluded. The study group consisted of 16 men and 60 women with a median age of 42 years (range 18-69) and a BMI of 25 (range 19-34). Eight patients had risk or comorbidity factors, 46 were classified ASA I, and 30 ASA II. Early postoperative course was uneventful in all cases but two patients developed a superficial wound abscess after hospital discharge. With a median follow-up of 44 months (range 12-72), incisional hernia was noted in six patients (7.9 %). Multivariate logistic analysis revealed that age (OR 1.08, 95 % CI 1.00-1.16, p < 0.038) and BMI (OR 1.37, 95 % CI 1.03-1.82, p < 0.029) were independent predictive factors of developing an incisional hernia. The incidence of hernia was, respectively, 15 % in patients with an age ≥ 50 and 33 % in patients with a BMI ≥ 30.

CONCLUSION

After SILC, we noted an incisional hernia rate of 8 %. To decrease the risk of developing that specific complication, SILC should only be proposed to young and non-obese patients.

New minimally invasive approaches for cholecystectomy: Review of literature

Laparoscopic cholecystectomy is the most commonly performed abdominal intervention in Western countries. In an attempt to reduce the invasiveness of the procedure, surgeons have developed single-incision laparoscopic cholecystectomy (SILC), minilaparoscopic cholecystectomy (MLC) and natural orifice transluminal endoscopic surgery (NOTES). The aim of this review was to determine the role of these new minimally invasive approaches for elective laparoscopic cholecystectomy in the treatment of gallstone related disease. Current literature remains insufficient for the correct assessment of emerging techniques for laparoscopic cholecystectomy. None of these procedures has demonstrated clear benefits over conventional laparoscopic cholecystectomy. SILC cannot be currently recommended as it can be associated with an increased risk of bile duct injury and incisional hernia incidence. NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice. As it is standardized and almost identical to the standard laparoscopic technique, MLC could lead to limited benefits without exposing patients to increased postoperative complications, being therefore adoptable for routine elective cholecystectomy. Technical challenges of SILC and NOTES cholecystectomy could be addressed with the evolution of new surgical tools that need to catch up with the innovative minds of surgeons. Regardless the place of these approaches in the future, robotization may be necessary to impose them as standard treatment.