Page 15 - World Journal of Laparoscopic Surgery

Mathews John

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“port site hernia” has also been used by many authors in in 1453 cases. Callery et al mentioned a verylow overall

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some other articles in similar situations. Initially,we started incidence, while Mayol et al stated that all these figures

searched this topic on Medline combining “trocar,” “hernia,” represent only the early results of laparoscopic surgery or

and “laparoscopy” and we got 186 reports in English. gynecologic laparoscopy (i.e. mostly diagnostic
Second, we combined “port,” “hernia,” and “laparoscopy” laparoscopy); currently all publications have drawn attention

the result was 90 reports in English. We then limited our to this problem as the number is increasing.Moreover there

search in the main operations such as cholecystectomy, will be a much higher true incidence and unknown

colon and rectal surgery, fundoplication (i.e. operation for percentage of patients who are asymptomatic might not

gastroesophageal reflux disease), and other gastric surgical seek medical examination 6, 8 that is not reported. Coda et

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procedures (e.g. obesity surgery) that are supposedto result al noted thatthe onset of trocar site hernia is not immediate

in the same operative insult as digestive surgery.Forty-four after surgery rather than early that might elude a surgeon in

articles were found on these procedures. Out of the 44 many surveys unless an extended follow-up procedure has

reports, 19 were case reports, 18 were original articles and been established. Recently,the incidence of trocar site hernia

7 were technical notes on “how to do it.” We found an has been reported as a postoperative complication in

additional 19 articles using the references of those obtained gastrointestinal surgery (colorectal surgery for cancer,
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(except for 3 gynecological articles). 5, 7,11 So total of 63 0.6%; colectomy for sigmoid diverticulitis,0.9%; Roux-

articles (24 case reports, 27 original articles, 7 technical en-Y gastric bypass, 0.3% 25 and 1.0%; 26 and gastric

notes, and 5 review articles). We finally chose trocar site banding, 0.5%). 27

hernia as the best and the relevant medical term as it was From 1995, a large series on digestive surgery oncompli-

the most frequently used and the one that most clearly cations of the trocar site in digestive surgery has been

expressed the condition. published. The incidence of trocar site hernia has been

We can classify trocar site hernias into 3 types according shown to be 0.65% to 2.80%. The studies based on Mayol

to the reported cases that have been analyzed. Early-onset et al 22 and Nassar et al 28-31 were based on data collected

type indicates dehiscence of the anterior fascial plane, prospectively, and patients have been followed up for several

posterior fascial plane, andperitoneum. The early-onset type months; therefore, it is supposed that the incidencereported

was recognized in many casereports as beginning to develop by them (1.50% to 1.80%) is reasonably standard.

in the early stages after surgery, often presenting as a small-
bowel obstruction. The late-onset type indicates dehiscence DISCUSSION

of the anterior fascial plane and posterior fascial plane. The Diagnosis

hernia sac of late-onset type is the peritoneum. The late-

onset type has often been recognized, in many large series, We can diagnose the special type of hernia without any

to be related to complications of the trocar insertion. Late- modalities. With the early-onset type we are able to locate

onset type hernias almost always develop in the late stages the site of herniationby computed tomography and surgically

reduce and repair the hernia with minimal enlargement of
several months after surgery.

the same trocar puncture wound, thus avoiding a full
The special type indicates dehiscence of the whole 41,43,46-48

abdominal wall. Protrusion of the intestine and other tissue laparotomy. In many other reports to diagnose early-

(e.g. greateromentum) is recognized. The first case, reported onset-type hernias a computed tomography was taken
9,16,32,34,38,42,45,50

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by Fear, wasof the special type: A loop of the bowel came and were effective in diagnosing them.

through a defect as the laparoscope and sheath were There were 3 reports of gastrointestinal contrast study which
33,38,44,49,52,53

withdrawn. Therefore, this first report points us toward was effective.

expressing a protrusion of the bowel and/or omentum as a There was an unknown proportion of asymptomatic

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“hernia,” although in this type there is no hernial sac. Three patients who do not get physicallyexamined, that belonged

case reports of the special type have been published since inlate-onset-type hernias although sometimes asymptomatic
then. 12-14 lumps were found.

Several large series of postoperative complications of
Prevention
laparoscopic cholecystectomy have been reported, where

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the incidence of trocar site hernia was 1 in 500 cases, 3 in 10 mm fascial defects or larger trocar sites shouldbe closed
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1983 cases, 1 in 800 cases, 11 in 1300 cases, and 10 to prevent hernia formation whenever possible. 4,10,20,34,35,38
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