Laparoscopic port site Richter's hernia – An important lesson learnt

Abstract

Introduction

We report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity.

Case report

A 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12 mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm³, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter's hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery.

Conclusion

Most port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.

1. Introduction

Laparoscopy has revolutionized surgical practice, and an increasing number of complex procedures are being performed using this technique. However a rapid expansion in the volume and complexity of laparoscopic surgery has been accompanied by complications, many of which are specific to abdominal access.^1–3 One such rare complication is the development of port site hernias, which is associated with significant morbidity.^1–6 We report the clinical course of our case to highlight the problem and also the investigation and management of this issue.

2. Case report

A thirty one year old normally fit and well female patient was admitted with a one day history of progressive lower abdominal pain initially periumbilical localizing to the right iliac fossa with associated anorexia, an episode of vomiting and low grade fever. The patient had no significant medical or surgical problems. General examination revealed a temperature of 37.6 °C, she was hemodynamically stable. Abdominal examination revealed a soft abdomen with maximum tenderness in the right iliac fossa. She also had rebound tenderness. Her blood tests revealed a total white cell count of 13100 and a C Reactive Protein (CRP) of 40.

Following an open technique of insertion of a 12 mm Umbilical port, Laparoscopy was performed which revealed a 7–8 cm long highly inflamed post ileal appendix in the right iliac fossa. Further ports in the suprapubic (10 mm) and the right iliac fossa (5 mm) were inserted and a standard three port laparoscopic appendicectomy was performed. Unfortunately, on post operative day three the patient developed progressive abdominal distension, crampy abdominal pain and bilious vomiting. She was febrile and tachycardic. On examination, the abdomen was distended and soft but diffusely tender; with maximal tenderness over the umbilical port site. The umbilical port site appeared inflamed and but there was no obvious swelling (Fig. 1). Her total white cell count had increased to 16500 and CRP to 145. Plain radiographs of abdomen showed dilated small bowel loops with multiple air fluid levels and no gas in the colon (Fig. 2). A CT scan of the abdomen was obtained to ascertain the cause for this clinical picture of small bowel obstruction. The CT scan showed a knuckle of small bowel herniating through the umbilical laparoscopic port site with dilated bowel proximal and collapsed bowel distal to the transition point located extrafascially in the midline (Figs. 3 and 4).

Fig. 1.

Umbilical port.

Fig. 2.

X-ray abdomen erect showing bowel obstruction.

Fig. 3.

CT scan of the abdomen demonstrating an umbilical port site hernia.

Fig. 4.

CT abdomen showing an extrafascially located knuckle of herniated bowel.

Diagnostic laparoscopy was done via a new left hypochondrial port located three cm below the left costal margin in the midclavicular line (Palmer's Point) and the hernia into trocar site with small bowel obstruction was noted (Fig. 5). The bowel loop could not be reduced laparoscopically, and the viability of the bowel at the margin of the hernial ring was suspect (Fig. 6). Based on the findings of the diagnostic laparoscopy a limited exploration of the umbilical trocar site was performed. The findings noted on diagnostic laparoscopy were confirmed. There was necrosis of the antimesenteric margin of the small bowel, with marginal viability of a 3–4 cm segment of herniated bowel. Limited bowel resection and anastomosis by means of two firings of the linear cutter 55 (Ethicon Endosurgery, India) was performed. The port site was closed in layers, with the fascia being closed with non absorbable polypropylene 2/0 suture. The patient made an uneventful recovery in the post operative period and was discharged five days later.

Fig. 5.

Laparoscopic view of the port site hernia.

Fig. 6.

Laparoscopic attempt at reducing the herniated small bowel.

3. Discussion

Trocar site hernias have been reported since the early days of laparoscopy.^2–4 The incidence of trocar site hernia is estimated to be between 0.65 and 2.80%.^4–6 Various factors have been implicated in the pathogenesis of trocar site hernias. Large trocar size, incomplete closure of fascia at the trocar site, midline trocars, stretching the port site for organ retrieval, the effect of a partial vacuum while port withdrawal, obesity, poor nutrition and operation site infection are some of the common factors associated with the development of these hernias.^1,4–8 The clinical presentation of trocar site hernias is variable and swelling and pain at incision site may be hard to differentiate from a hematoma or wound infection.^1,5,6,8,9 Most hernias present within 10 days from the procedures, even though delayed hernias have been reported up to a year from the initial operation.^1,5,6,8,10 A classification has been suggested depending on the time of presentation from the index operation.⁶ The early onset type was within two weeks, most commonly with small bowel obstruction. The late onset type occurred after two weeks and had dehiscence of fascial plane with a sac consisting of peritoneum. The third category included special types of ventral abdominal hernia. The clinical course of port site hernia can be varied and depends on the extent and nature of the herniated content.^1,6

CT scan is a useful adjunct to differentiate port site hematoma from incarcerated small bowel and ileus from small bowel obstruction and acts as a vital guide to intervention.^11,12 A study done by Tanouchi et al. showed that 86.3% of hernias occurred in sites where the trocar diameter was 10 mm or more.⁶ Fascial closure of trocar sites more than 10 mm has been found to decreases incidence of herniation and significantly decreases postoperative morbidity and related costs.^{1,4–6,15,17,18} Deflation of pneumoperitoneum prior to removal of ports, fascial closure techniques using fascial closure device, suture carrier, Deschamps needle, port plugs are other techniques described to reduce the chances of trocar site herniations.^13–19 Some authors have also reported a lower incidence of hernias with the use of a paramedian incision and non bladed trocars, but these are not foolproof as has been shown by a recent case report.^17–20 The management of most of these hernias includes access to the hernia by extending the trocar site, laparoscopy or an explorative laparotomy and then reduction of the hernia and further surgeries based on the bowel viability.^1,4–9

In conclusion, it is necessary to repair the fascial and peritoneal layers to prevent port site hernia. Prompt investigation and further intervention may reduce unfavorable events if a port site hernia is suspected. Most port site hernias present within 10 days of the primary procedures. CT scan is a helpful adjunct to diagnose port site herniation. The knowledge of such a complication and its early diagnosis are important to avoid complications.

Conflicts of interest statement

None declared.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.