Strangulated lateral port-site hernia: Lessons to be learned

August 8, 2007
Surgical Rounds®, August 2007, Volume 0, Issue 0

AE Agaba,

AE Agaba, MD

Surgical Resident

Department of Surgery

Long Island Jewish Medical Center

New Hyde Park, NY

D Appleyard, MD

Surgical Resident

Department of Surgery

Walsgrave General Hospital

Coventry, United Kingdom

V Sasthakonar,MD

Surgical Resident

Department of Surgery

Long Island Jewish Medical Center

New Hyde Park, NY

PO Agaba, MD

Surgical Resident

Department of Surgery

Walsgrave General Hospital

Coventry, United Kingdom

K Hardiment, MD

Surgical Resident

Department of Surgery

Walsgrave General Hospital

Coventry, United Kingdom

G Pavlou, MD

Surgical Resident

Department of Surgery

Walsgrave General Hospital

Coventry, United Kingdom

LS Wong, MD

Attending Colorectal Surgeon

Department of Surgery

Walsgrave General Hospital

Coventry, United Kingdom

Complications of laparoscopic operations can be difficult to recognize. This report emphasizes the importance of prevention and early recognition and treatment when such injuries occur. Port sites pose a low incidence of complications such as herniation, and any sites measuring 10 mm or larger are closed to prevent such complications. Although cannulas and trocars are designed to be atraumatic, a defect is made in the fascia and muscle layers, and this defect can become a potential source of weakness and herniation. In general, any cannula site that is 10 mm or larger should be closed with sutures to prevent a hernia. Another lesson to be learned from this report is that any bulge in a port site should be assumed to be a hernia and immediate exploration should be undertaken. In this case, recognition and treatment were delayed. This resulted in strangulation of the incarcerated small bowel, which required resection. Early recognition and treatment may have allowed simple reduction of the hernia and closure of the defect.

Thomas Gadacz, MD

Series Guest Editor

Professor Emeritus

Department of Surgery

Medical College of Georgia

Augusta, GA

With the advent of laparoscopy came the unique issue of creating openings for instruments to be inserted into the abdominal cavity. Nearly half of all major complications in laparoscopic surgery are thought to be related to the site and procedure used to access the abdominal cavity.1 Despite advances in laparoscopic equipment over the past decade, access-related complications continue to occur, such as incisional hernias and damage to major blood vessels, the bladder, and intestines. Serious access-related complications appear to be rare but can lead to increased morbidity when they do occur. Herniation of the bowel through port sites is uncommon and can be difficult to diagnose. Often the diagnosis is delayed, resulting in infarction of the involved bowel segment. We report a case of small bowel herniation that presented as a lump in the right lateral port site.

Case report

A fit 84-year-old man was admitted to the hospital for a planned laparoscopic herniorrhaphy to treat a recurrent right inguinal hernia. Under general anesthesia, the patient was placed in the supine position and a urinary catheter was inserted after intravenous (IV) Ringer's lactate was administered. A 1-cm skin incision was made below the umbilicus, and a 12-mm nonbladed trocar cannula with a laparoscope was inserted into the intraperitoneal cavity using a Hasson open technique to create a closed pneumoperitoneum.2 After preliminary laparoscopy, two additional 10-mm ports were inserted in the left and right flanks, lateral to the infraumbilical port site, using videoscopic guidance.

The right inguinal hernia was reduced, and a preperitoneal space was established. Polypropylene mesh was placed across the defect and secured with staples. Fascial closure of the 12-mm port site was performed using polyglactin 0 sutures, but the lateral port sites were not closed. All skin incisions were closed using 3-0 polyglactin 910 sutures.

In the immediate postoperative period, the patient experienced acute urinary retention after removal of the urethral catheter, and it was reinserted. On postoperative day 1, the patient started vomiting and reported lower abdominal pain associated with a painful lump on the right lateral port site. Although he had passed flatus earlier that day, he had had no bowel movements since the operation.

On physical examination, he was febrile with a temperature of 101.5°F. He was hemodynamically stable, with a blood pressure of 148/88 mm Hg and a pulse rate of 86 beats per minute. Abdominal examination found an approximately 5-cm, tender, nonreducible lump overlying the right lateral port site. A biochemical profile revealed moderate dehydration and a white blood cell count that was marginally elevated at 13 x 109/L (normal, 4?11 x 109/L). A supine radiograph of the abdomen revealed distended small bowel loops (Figure).

The patient was treated using nasogastric tube suctioning, IV rehydration, and IV administration of the antibiotics metronidazole and cefuroxime. His urine output was strictly monitored. When the patient's condition did not improve despite these measures, he underwent emergency laparotomy via a tranverse incision joining all three port sites. During the operation, about 6 inches of gangrenous small bowel was found to have herniated through the right lateral port site. A limited small bowel resection and a stapled side-to-side anastomosis were performed. The peritoneal cavity was thoroughly irrigated with 2 L of warm normal saline. The abdominal wound was closed with loop polydioxanone using mass closure. The patient had an unremarkable recovery and was discharged home on postoperative day 10. At 2- and 6-week follow-up visits, the patient was in satisfactory condition and was discharged from further follow-up.

Discussion

Laparoscopic procedures have many benefits compared with open ones, but access-related complications, such as intestinal herniation, bleeding, and injury to the viscus, can occur. These require early recognition and prompt intervention. Although the reported incidence of incisional hernia is low (less than 0.17%), its actual incidence is likely much higher, because many patients are asymptomatic or do not return to their primary surgeon for follow-up care.3,4

Several factors contribute to the development of incisional hernias. Most laparoscopic surgeons agree that the diameter of the cannula or port is the single most common cause of incisional or port-site hernias. Emerging evidence suggests that transmuscular placement of a port, the use of small trocars with conical obturators, and the evacuation of air from the peritoneal cavity before the removal of a port serve to significantly decrease the incidence of incisional hernias.3,5 The location of the port site also may influence the risk for herniation. Epigastric ports tend to place patients at lower risk for developing incisional hernias due to the difference in pressure gradients across the abdominal wall and the gravitational pull when the patient is standing.

In our patient, who was physically fit, the lateral ports were inserted transmuscularly in a Z-fashion. We chose this approach because we thought that the abdominal musculature and normal fascial elasticity would inhibit herniation by acting as a shutter mechanism over the defect. It is possible that the herniation developed secondary to the partial vacuum effect created when the trocars were withdrawn. As a result of this case, we have changed our practice to include removal of all trocars under videoscopic guidance and ensure closure of all port sites under direct vision.

Although the risk of incisional hernia is much higher in cases where large trocars are used, there have been reports of incisional hernias occurring in 5-mm port sites.6 Carson and colleagues advocate a nonclosure policy for fascial defects created with nonbladed trocars.7 We disagree with this recommendation. Although nonbladed trocars bluntly displace tissue and muscle fibers laterally, thereby causing less tissue damage than cutting trocars, the risk for incisional hernia remains. It is possible that laterally displaced muscle fibers do not return to their original state, allowing omentum and bowel to herniate through such a defect. It is for this reason that we concur with the recommendations of clinicians who advocate closing any port sites larger than 5 mm.8-10

Reissman and associates reported a case of an incarcerated hernia at a lateral port site and advised routine fascial repair of lateral port sites measuring 10 mm or more in diameter, especially in elderly patients.11 Patterson and colleagues reported three cases of an incarcerated hernia at a port site and recommended that all port sites with a diameter of 10 mm or more be repaired in obese patients.12

We no longer think that port sites should be closed blindly, because there are reported incidences of port-site herniation following such closures. We recommend closing these sites under laparoscopic videoscope control, and the last port should be closed by picking up the fascia with Kocher clamps and repairing the defect under direct vision.

Conclusion

If the cannula or port site is 10 mm or larger in diameter, hernias can occur, despite preventative measures such as entering in a Z-fashion or using a noncutting trocar. Recognition and early treatment of port-site hernias avoids strangulation of an incarcerated hernia and the need for bowel resection. Although port site hernias after laparoscopic surgery are uncommon, they remain a significant cause of postoperative morbidity and require prompt intervention if extensive bowel resection is to be avoided. A bulge at a trocar site should alert a surgeon to this complication.

Most surgeons do not routinely close lateral port sites because it is commonly thought that the fascial and muscular composition of these sites pose such little risk of herniation that the extra time and effort required to repair them is not justified. We report a case where a strangulated port hernia revealed itself as a tender bulge on the lateral port site on the first postoperative day. This report underscores the significance of performing meticulous closure of all trocar sites that are 10 mm or greater under videoscopic guidance. Because there have been reports of incisional hernias occurring in 5-mm port sites, we also advise giving consideration to closing any port site 5 mm or larger.

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