Background
Trocar site hernias (TSHs) can affect the outcome of laparoscopic surgery in 0.2–3.1% of cases.1–3 Factors influencing the development of TSHs include: the number and diameters of trocars; a peritoneal defect greater than the trocar size; midline insertion; the type of trocar tip; manipulation of the trocar site; methods of entry and closure; operative time; infection at the trocar site.3,4
TSHs may have an early or late onset.2 In early onset TSHs, viscera herniate through the peritoneal defect in the first few days after surgery. In late onset TSHs, the peritoneum remains intact and viscera herniate with the peritoneum. TSHs are usually asymptomatic. Occasionally, they can present with bowel obstruction that necessitates emergency surgery.
Technique
We propose a simple and non-time consuming technique to repair fascial defects whenever they are indicated. Under direct reverse vision of the defect with a 30° laparoscopic camera, the measurement (using as a reference the size of the grasper branch [5mm]) can be undertaken readily. Alternatively, the size of the fascial defect can be measured directly using a sterile ruler. We suggest repair of fascial defects ≥8mm independent of the trocar size used. Smaller defects have a very low prevalence of TSH and can be left in situ. We are aware that with our method of measurement we may repair more defects than is absolutely necessary.
Discussion
Closure of the fascia for wounds >10mm in diameter is essential.4,5 However, if the wounds are ≤10mm in diameter, the decision regarding repair is controversial.1 In fact, trocars that cause aponeurotic defects <10mm in diameter rarely result in herniation or bowel obstruction.1
References
- 1.Dulskas A, LuneviČius R, Stanaitis J. A case report of incisional hernia through a 5mm lateral port site following laparoscopic cholecystectomy. J Minim Access Surg 2011; 7: 187–189. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Swank HA, Mulder IM, la Chapelle CF et al. Systematic review of trocar-site hernia. Br J Surg 2012; 99: 315–323. [DOI] [PubMed] [Google Scholar]
- 3.Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004; 139: 1248–56. [DOI] [PubMed] [Google Scholar]
- 4.Freedman AN, Sigman HH. Incarcerated paraumbilical incisional hernia and abscess: complications of a spilled gallstone. J Laparoendosc Surg 1995; 5: 189–191. [DOI] [PubMed] [Google Scholar]
- 5.Kadar N, Reich H, Liu CY et al. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol 1993; 168: 1493–1495. [DOI] [PubMed] [Google Scholar]