Incisional Hernia and Infection in Laparoscopic Surgery
It is not that the incidence of laparoscopic incisional hernia is unknown, it is clear that the complication has been underreported. Recent reports of incisional hernia after laparoscopy have stressed the relationship of this complication with the use of ports 10 mm in diameter or larger. In our opinion, this can probably be attributed to increased operating times which result in excessive manipulation of the port site, thereby widening the fascial and peritoneal defects.
While no incision is immune to the risk of herniation, those defects that are 10 mm or more in diameter are particularly vulnerable. The increasing number and size of the incisions, ID combination with the surgeon’s variable propensity to close them, will likely further contribute to the increasing incidence. Another important contributing factor may be the use of cannula anchoring devices that effectively increase the diameter of the incision by 2 to 3 mm.
Diagnosis
After laparoscopy the most common hernia appears to occur in the immediate postoperative period where bowel or omentum passes through the unopposed or inadequately repaired defect. The patient may be symptomatic or can present with any or a combination of pain, fever, periumbilical mass, obvious evisceration, and the symptoms and signs of mechanical bowel obstruction, often within hours and usually within the first postoperative week. Consequently, the surgeon should take care not to casually disregard the patients who talk about symptoms consistent with herniation.
Because Richter’s hernias contain only a portion of the circumference of the bowel wall in the defect, the diagnosis is often delayed. It is likely that such lesions most commonly occur in incisions that are made away from the midline. The initial presenting symptom is usually pain, since the incomplete obstruction and still allows the passage of intestinal content. Fever can present if incarceration occurs, and peritonitis may result from the subsequent perforation. The diagnosis is difficult to make and requires a high index of suspicion. Ultrasound or CT scanning may be useful in confirming the diagnosis.
While many defects likely remain asymptomatic, late presentation may occur if bowel or omentum becomes trapped. The symptoms and findings are similar to that described for earlier presentations.
Prevention
The underlying fascia and peritoneum should be closed not only when using trocars of 10 mm and larger as previously suggested but also when extensive manipulation is performed thorough a 5 mm trocar port, causing extension of the incision.
There are a number of unproven but seemingly logical pre-emptive strategies. First, it is desirable to use the smallest possible cannula whenever possible recognizing that hernia has even been reported in conjunction with the use of 5 mm trocars. Second, the “Z-track” insertion method, particularly applied, in the umbilicus, may be of value. This approach offsets the skin and fascial incisions by entering the subcutaneous tissue, then sliding the conically-tipped trocar along the fascia for a short distance prior to penetrating it. Such a track is purported to close like a curtain, reducing the incidence of hernia. Third, all ancillary cannula should be removed under direct vision to ensure that bowel is not drawn into the incision. Insertion of an obturator (or a laparoscope) into the cannula may further prevent suction from drawing bowel or omentum into the incision. Fourth, at least those incisions 10 mm or greater in diameter should undergo fascial closure under direct laparoscopic vision, thereby preventing incorporation of bowel. This may be accomplished by using a small caliber diameter laparoscope through one of the narrow cannula to direct incisional closure. A narrow diameter, three-quarter round, needle (Ethicon UR-6) facilitates such a closure, as does the use of one of the newer devices. Finally, the laparoscope cannula should be removed with the laparoscope in position, preventing accidental incorporation of bowel.
If the final incision is of sufficiently large diameter to require closure, blind insertion of needles may be avoided by prepositioning sutures. They are placed when the laparoscope is in another location and tied following removal of the final cannula. The sutures should be used to elevate the abdominal wall as the laparoscope and cannula are simultaneously removed, looking down the endoscope to ensure that bowel or omentum is not inadvertently drawn into the wound.
Management
Management of postoperative development of incisional hernia after laparoscopy is same as that of open surgery. Management of laparoscopic incisional defects depends upon the timing of the presentation and the presence or absence of entrapped bowel and its condition. Evisceration will always require surgical intervention. If the diagnosis is made in the recovery room, the patient may be returned to the operating room, the bowel or omentum replaced in the peritoneal cavity (provided there is no evidence of necrosis or suture incorporation), and the incision repaired, usually under laparoscopic guidance. However, if the diagnosis is delayed it is likely that the bowel is incarcerated and at risk for perforation. In such circumstances, resection will likely be necessary, usually via laparotomy. Most gynecologic surgeons should request general surgical consultation.
Infection
Wound infection following laparoscopy is less but not rare. Even a case of postoperative wound infection due to Mycobacterium chelonae also been reported. A 35-year- old woman presented with multiple erythematous nodules, plaques and discharging sinuses over the abdomen, 45 days after she had undergone laparoscopic ovarian cystectomy. The seropurulent discharge from the wound showed acid- fast bacilli on Ziehl-Neelsen stain and culture yielded Mycobacterium chelonae. The patient responded to clarithromycin and doxycycline. The source of infection was probably contaminated water or disinfectant solution used for sterilization of laparoscopic instruments. In the urologic and general surgical wound infection rates seem to range from 5 to 6 per 1000 cases. While the vast majority of wound infections are handled successfully with expectant management, drainage, or antibiotics, severe necrotizing fascitis has been reported.
Many other types of postlaparoscopy infection have been reported including bladder infection, pelvic cellulitis, and pelvic abscess. While bacteremia has been described, there have been no reports of disseminated infection following laparoscopic surgery.
This is true that the risk of infection associated with laparoscopy is low; much lower than that associated with open abdominal or vaginal surgery. Nevertheless, until clinical studies dictate otherwise, it is prudent to continue to practice strict sterile technique and to offer appropriate prophylactic antibiotics to selected patients. These could include those with enhanced risk for bacterial endocarditis, as well as those who are to undergo procedures (e.g. laparoscopic hysterectomy), suspected of increasing, the chance of wound or vault infection. Patients should be instructed to routinely take their temperature following discharge and to immediately report fever of 38 °C or more.
It is not that the incidence of laparoscopic incisional hernia is unknown, it is clear that the complication has been underreported. Recent reports of incisional hernia after laparoscopy have stressed the relationship of this complication with the use of ports 10 mm in diameter or larger. In our opinion, this can probably be attributed to increased operating times which result in excessive manipulation of the port site, thereby widening the fascial and peritoneal defects.
While no incision is immune to the risk of herniation, those defects that are 10 mm or more in diameter are particularly vulnerable. The increasing number and size of the incisions, ID combination with the surgeon’s variable propensity to close them, will likely further contribute to the increasing incidence. Another important contributing factor may be the use of cannula anchoring devices that effectively increase the diameter of the incision by 2 to 3 mm.
Diagnosis
After laparoscopy the most common hernia appears to occur in the immediate postoperative period where bowel or omentum passes through the unopposed or inadequately repaired defect. The patient may be symptomatic or can present with any or a combination of pain, fever, periumbilical mass, obvious evisceration, and the symptoms and signs of mechanical bowel obstruction, often within hours and usually within the first postoperative week. Consequently, the surgeon should take care not to casually disregard the patients who talk about symptoms consistent with herniation.
Because Richter’s hernias contain only a portion of the circumference of the bowel wall in the defect, the diagnosis is often delayed. It is likely that such lesions most commonly occur in incisions that are made away from the midline. The initial presenting symptom is usually pain, since the incomplete obstruction and still allows the passage of intestinal content. Fever can present if incarceration occurs, and peritonitis may result from the subsequent perforation. The diagnosis is difficult to make and requires a high index of suspicion. Ultrasound or CT scanning may be useful in confirming the diagnosis.
While many defects likely remain asymptomatic, late presentation may occur if bowel or omentum becomes trapped. The symptoms and findings are similar to that described for earlier presentations.
Prevention
The underlying fascia and peritoneum should be closed not only when using trocars of 10 mm and larger as previously suggested but also when extensive manipulation is performed thorough a 5 mm trocar port, causing extension of the incision.
There are a number of unproven but seemingly logical pre-emptive strategies. First, it is desirable to use the smallest possible cannula whenever possible recognizing that hernia has even been reported in conjunction with the use of 5 mm trocars. Second, the “Z-track” insertion method, particularly applied, in the umbilicus, may be of value. This approach offsets the skin and fascial incisions by entering the subcutaneous tissue, then sliding the conically-tipped trocar along the fascia for a short distance prior to penetrating it. Such a track is purported to close like a curtain, reducing the incidence of hernia. Third, all ancillary cannula should be removed under direct vision to ensure that bowel is not drawn into the incision. Insertion of an obturator (or a laparoscope) into the cannula may further prevent suction from drawing bowel or omentum into the incision. Fourth, at least those incisions 10 mm or greater in diameter should undergo fascial closure under direct laparoscopic vision, thereby preventing incorporation of bowel. This may be accomplished by using a small caliber diameter laparoscope through one of the narrow cannula to direct incisional closure. A narrow diameter, three-quarter round, needle (Ethicon UR-6) facilitates such a closure, as does the use of one of the newer devices. Finally, the laparoscope cannula should be removed with the laparoscope in position, preventing accidental incorporation of bowel.
If the final incision is of sufficiently large diameter to require closure, blind insertion of needles may be avoided by prepositioning sutures. They are placed when the laparoscope is in another location and tied following removal of the final cannula. The sutures should be used to elevate the abdominal wall as the laparoscope and cannula are simultaneously removed, looking down the endoscope to ensure that bowel or omentum is not inadvertently drawn into the wound.
Management
Management of postoperative development of incisional hernia after laparoscopy is same as that of open surgery. Management of laparoscopic incisional defects depends upon the timing of the presentation and the presence or absence of entrapped bowel and its condition. Evisceration will always require surgical intervention. If the diagnosis is made in the recovery room, the patient may be returned to the operating room, the bowel or omentum replaced in the peritoneal cavity (provided there is no evidence of necrosis or suture incorporation), and the incision repaired, usually under laparoscopic guidance. However, if the diagnosis is delayed it is likely that the bowel is incarcerated and at risk for perforation. In such circumstances, resection will likely be necessary, usually via laparotomy. Most gynecologic surgeons should request general surgical consultation.
Infection
Wound infection following laparoscopy is less but not rare. Even a case of postoperative wound infection due to Mycobacterium chelonae also been reported. A 35-year- old woman presented with multiple erythematous nodules, plaques and discharging sinuses over the abdomen, 45 days after she had undergone laparoscopic ovarian cystectomy. The seropurulent discharge from the wound showed acid- fast bacilli on Ziehl-Neelsen stain and culture yielded Mycobacterium chelonae. The patient responded to clarithromycin and doxycycline. The source of infection was probably contaminated water or disinfectant solution used for sterilization of laparoscopic instruments. In the urologic and general surgical wound infection rates seem to range from 5 to 6 per 1000 cases. While the vast majority of wound infections are handled successfully with expectant management, drainage, or antibiotics, severe necrotizing fascitis has been reported.
Many other types of postlaparoscopy infection have been reported including bladder infection, pelvic cellulitis, and pelvic abscess. While bacteremia has been described, there have been no reports of disseminated infection following laparoscopic surgery.
This is true that the risk of infection associated with laparoscopy is low; much lower than that associated with open abdominal or vaginal surgery. Nevertheless, until clinical studies dictate otherwise, it is prudent to continue to practice strict sterile technique and to offer appropriate prophylactic antibiotics to selected patients. These could include those with enhanced risk for bacterial endocarditis, as well as those who are to undergo procedures (e.g. laparoscopic hysterectomy), suspected of increasing, the chance of wound or vault infection. Patients should be instructed to routinely take their temperature following discharge and to immediately report fever of 38 °C or more.
