Page 16 - World Journal of Laparoscopic Surgery

Incisional Hernias after Laparoscopic Surgery

10
Moreover, Crist and Gadacz mentioned that, in general, should stick to this rule of deflating intra-abdominal
5.5 mm facial defects by trocar sites need not to be closed. compressed gas before closure.

However, Sanz-Lopez et al 8 insisted that the general We believe that closing the fascialdefect and peritoneum

consensus is that trocar site hernias of 5 mm and greater in is the only effective way to prevent trocar site hernias, and

diameter should be closed at the fascial level, and thatdefects thatthe other methods should be used after improper closure

of any size especially in children should be closed. Some for the worst cases. When active manipulation through a 5
authors have stated their opinion that all 5 mm ports sites mm port for prolonged time has occurred then to avoid

routinely might not be necessary to close, but in active complications the fascial defect should be closed.
manipulation during prolonged procedures, to avoid

complications they should be closed. 54,55 TREATMENT
How to properly close a fascial defect is the problem. 2

15

Matthews et al reported that there were trocar site hernias Duron et al investigated 24 cases of reoperated mechanical
intestinal obstruction postoperative following laparoscopic
due to incomplete closure of fascial planes and that the
surgery that were;11 (46%) were due to trocar site hernia,
peritoneum should also be closed along with the fascia to
8 (33%) to adhesions, 4 (17%) to gastric bands, and 1 to
obliterate the preperitoneal space, and thus postoperative
complication of hernia can be prevented. Velasco et al 51 cecal volvulus. The median interval to reoperation was

significantly shorter for trocar site hernias (8 days) than
mentioned that under direct vision only the closure should

be done, and it should incorporate all abdominal wall layers for adhesions (25 days) or gastric bands (22.5 days). To
3

to eliminate the peritoneal defect. Callery et al stated that conclude that trocar site hernia will be early onset of small-

51

even if to extent the skin incision, all largetrocar sites should bowel obstruction. Velasco et al reported that all his
patients required surgery to resolve small-bowel obstruction
be closed meticulously. We consider that larger trocar site
with early post laparoscopic bowel obstruction. They set
of 10 mm and above should be closed completely (meaning

closureof all layers including the peritoneum) with adequate for decision-making as 14 days after surgery to be the

muscle relaxation. Thus, the lateral trocar should also be turning point. Moreover, some authors advised that

correctly diagnosing Richter hernia will help to lessen any

closed as there are incidences of trocar site hernia at the
lateral port. 56 delay in a postlaparoscopic patient with symptoms ofsmall-
44, 50

Some surgeons recommended a fascial closure device, 16 bowel obstruction. Therefore, further procedures on
57
58
a spinal cord needle, a suture carrier, a 2 mm trocar, 54 patients with a small-bowel obstruction is advisable within

2 weeks of laparoscopic surgery. If diagnosis of the
59
or a Deschamps needle to close the fascia and the

peritoneum together. It would be advantageous to try one obstruction cannot be ruled out, computed tomography

will be effective. Nonoperative management (nasogastric
of these techniques to close all the layers so there won’t be

any defects. It might be better to use a device like those suction and other methods) will often end up in waste of
time and money, and they will sometimes lead to critical

mentioned earlier if the fascial defect must be closed in a 5
conditions (i.e. strangulation).
mm trocar site.

Some authors have reported a new type of trocar: as 10
CONCLUSION
to 12 mm nonbladed trocar sites which is very useful and

do not require fascial closure above the arcuate line in In this review article, we tried to make a classification of

60
nonmidline port sites, so the trocar site hernias frequency trocar site hernia by studying previous reports and articles

could be lowered significantly, from 1.83 to 0.17%, by published. We think that a more accurate clinical

switching from a sharp cutting device to a cone-shaped identification is possible from this categorization.These will

61

trocar tip; and a trocar that expands radiallymight be useful be useful to prevent complications if the surgeon is able to

to prevent hernias. It is supposed that these devices are correlate between the identified types and clinical

recognized as useful, but before abandoning fascial closure manifestations before the laparoscopic procedure.

a randomized large prospective study of digestive surgery The only surgeon who does not encounter complications
is needed. is one who is not operating. Complications can happen even
Many authors have advised to deflate air completely in the best of the best hands and it is important that these

before port removal then fascial closure so as not to draw are recognized on table and addressed immediately. The

omentum and intestines into the fascial defect. 2,6,8,32 We importance of adequate training and the value of proper
World Journal of Laparoscopic Surgery, January-April 2010;3(1):13-17 15