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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 27-30

Port-site hernia leading to bowel obstruction and its logomachy


1 Department of Surgery, Civil Hospital Palampur, Kangra, Himachal Pradesh, India
2 Department of Surgery, Shri Lal Bahadur Shastri Government Medical College, Ner Chowk, Himachal Pradesh, India
3 Department of Radiology, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Submission03-Aug-2020
Date of Acceptance06-Aug-2020
Date of Web Publication14-Jun-2022

Correspondence Address:
Dr. Ankit Shukla
Civil Hospital Palampur, Kangra - 176 061, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_7_20

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  Abstract 


Since the birth of laparoscopic surgery, the morbidity in context to conventional surgery has hugely reduced; nevertheless, the laparoscopic surgery has its own specific complications, one of them being port-site hernia, which can be devastating. As the minimal access surgery is advancing to the single-port or single-incision laparoscopic surgery and bariatric and robotic surgery, the rise in port site hernia will be noticeable. However, the dilemma still exists regarding the pathogenesis, prophylactic closure of larger port sites, and the optimum technique of management of port-site hernia due to a lack of high level of evidence. Herein, we present a female patient with port-site hernia, leading to small bowel obstruction from one of the working ports.

Keywords: Laparoscopy, port-site hernia, trocar site hernia, ventral hernia


How to cite this article:
Shukla A, Verma V, Dogra A, Shukla R, Sharma A. Port-site hernia leading to bowel obstruction and its logomachy. Saudi J Laparosc 2021;6:27-30

How to cite this URL:
Shukla A, Verma V, Dogra A, Shukla R, Sharma A. Port-site hernia leading to bowel obstruction and its logomachy. Saudi J Laparosc [serial online] 2021 [cited 2022 Dec 7];6:27-30. Available from: https://www.saudijl.org/text.asp?2021/6/1/27/347478




  Introduction Top


Since the dawn of laparoscopic surgery, the morbidity related to conventional surgery has drastically reduced; nevertheless, the laparoscopic surgery has its own peculiar stumbling blocks and is not exempt from complications. One of the complications born out of it was trocar or port-site hernia, which can be defined as incisional hernia occurring through the point from where the trocar or port is inserted into the cavity in minimal access surgery. As the minimal access surgery is advancing to the single-port or single-incision laparoscopic surgery and laparoscopic bariatric and robotic surgery, the upsurge of port-site hernia is perceptible. Port-site hernia can be a devastating complication, and every sincere effort has to be made to prevent it; however, we are still lagging in the knowledge of its pathogenesis, prevention, and management. We are here reporting a case of a female with port-site hernia following laparoscopic appendicectomy, leading to small bowel obstruction from one of the working ports.


  Case Report Top


A 54-year-old female was admitted to our secondary care hospital in the surgery ward with the complaints of pain in the left iliac fossa for the last 4 days and vomiting and constipation for the last 2 days. The pain was colicky in nature to start with and then became localized to left iliac fossa. The patient had a history of undergoing laparoscopic surgery for appendicitis 1 year ago with no history of postoperative wound sepsis and closure port site according to the old records. On examination, abdomen was distended and there was a visible bulge in the left iliac fossa at the previous port site used for appendicectomy, which was tender to touch; rest of the abdominal examination was normal without any signs of peritonitis or skin discoloration [Figure 1]. On physical examination, the patient was well nourished with the body weight of 65 kg, mildly dehydrated, blood pressure 114/70 mmHg, and pulse rate was 106/min. A plain abdominal radiograph showed multiple air–fluid levels suggestive of intestinal obstruction. Contrast-enhanced computed tomography scan of the abdomen was done, which revealed a defect in the left iliac region with the small bowel protruding from the defect, which was approximately 2.5 cm in its largest dimension.

The patient was resuscitated with isotonic fluids, nasogastric decompression, antibiotics, and analgesics and prepared for open exploration. On exploration, the small bowel was seen herniating through the previous left iliac fossa port [Figure 2]; the bowel was viable and reduced back to the abdominal cavity. The hernia defect was approximately 3 cm in length and 2 cm in width [Figure 3]; the noteworthy observation was that the inferiolateral fascial tissue was very close to the anterior iliac spine (<1 cm), which could have been the reason for the formation of the incisional port-site hernia in our case. The defect was closed primarily with nonabsorbable sutures, and mesh could not be placed due to a lack of adequate overlap. The postoperative period was uneventful, and the patient was discharged on the 8th postoperative day after the removal of sutures. The patient is doing well on follow-up after 2 years of port-site hernia repair with simple sutures.
Figure 1: Abdominal bulge in left iliac fossa

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Figure 2: Small bowel herniation

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Figure 3: Hernia defect

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  Discussion Top


The first description of port-site hernia was given by Fear in the year 1968 in his series on laparoscopy in gynecological diagnosis.[1] It was in the year 1991 that the first case of port-site hernia with obstruction of small bowel was reported following laparoscopic cholecystectomy in the early postoperative period with the aid of computed tomography by Maio and Ruchman.[2] In the year 1993, Crist and Gadacz defined trocar site hernia as the development of a hernia at the cannula insertion site, and this term has been used by many since then.[3] Multiple other terminologies have been used to describe it such as port-site hernia, trocar site hernia, port-site incisional hernia, and port-site dehiscence; however, port-site hernia and trocar site hernia are the two frequently used.

Most of the studies reveal the incidence of port-site hernia to be ranging from 1% to 22%, but the exact incidence can be higher as many of the port-site hernias remain asymptomatic and usually are not dealt by the primary operating surgeons; moreover, all cases are not reported in the literature.[4] Port-site hernia in the literature has been reported with the same incidence in the pediatric age group as the adult group.[5] Some rise is noted in cases in bariatric and laparoscopic colorectal surgery studies due to the use of larger size ports and also in single-incision laparoscopic surgery. Port-site hernias were classified in 2004 by Tonouchi et al. into three types: early onset, late onset, and special type; the first two are classified on the basis of the timing of appearance, and the special type is the rarest depicting dehiscence of the whole abdominal wall.[6] Hernial sac is present only in the late-onset type. Nonetheless, one variety of port-site hernia has not been classified yet, which is seen in morbidly obese patients where the peritoneum gets thickened and leads to the formation of the Richter type of hernia despite the adequate closure of fascial defect.[7] This variety demands classification as the number of bariatric procedures has increased, and this peritoneal type hernia without fascial defect will be noticed more.

Several factors have been associated with the risk of port-site hernia and they are usually segregated into patient factors or surgical factors. Most important factors of these are obesity, increasing age, wound infection, malignancy, steroid use, females, site of port placement, trocar diameter, trocar design (bladed, nonbladed, and radially expanding), long duration of the surgery, excessive manipulation of port site, extension of the extraction port or its stretching for retrieval of organs, and faulty or nonclosure of the port site by some.[8] Single-incision laparoscopic surgery is on the rise and has been considered by some that this might increase the incidence of port-site hernia.[9] The increased risk is more in obese due to increased preperitoneal space and increased abdominal pressure. The closure of the port-site fascial defect is favored by most in adults and children to reduce the incidence of hernia, but the evidence for this is lacking.[10],[11] So as of today, there is still a dilemma that the port-site fascial suturing should be done or not.

Moreover, nonbladed trocars consisting of conical blunt devices, bladeless trocar, and radially dilating system are less traumatic than the bladed trocars.[12] The fascial injury due to nonbladed trocar is lesser in area with shorter length and breadth, and they separate the fascial tissue instead of cutting or transecting as in bladed trocar, resulting in better healing of facial defect and bear less chance of port site hernia. Laparoscopists using nonbladed trocar prefer not to close the fascial defect.[13] Some studies on bariatric and robotic-assisted gynecological procedure for malignancy have used nonbladed trocars up to 12 mm without fascial closure without an increase in port-site hernia.[14],[15] According to the site of placement, midline port sites, especially umbilicus, are more prone to herniated than the lateral ones. A few ways mentioned to protect port-site hernia are by paramedian insertion, passing the lateral trocar obliquely, or fashioned as Z-tract such that the internal and external fascial layers overlie at different levels.[13]

Diagnosis is established clinically; the port-site hernia presents as excessive pain, swelling at the port site, or change of color similar to hematoma in the early period or as a partial or complete obstruction in the late presentation or as Richter's hernia. The most helpful investigation is the computed tomography, which is vital in establishing the diagnosis and verifying and assessing the viability of contents; other investigations that aid in the diagnosis are plain X-ray abdomen and ultrasonography. The consequences of the port site can be fatal, so every diligent precaution has to be taken to prevent it. While attempting to remove the port and instrument after completion of surgery, Especial precaution is taken to remove all ports under vision and leaving the camera port and then the gas is removed before removing the camera port so that omentum and bowel are not trapped in the fascial defect due to high intra-abdominal pressure. If the fascial closure is done, care is taken that the bowel loops are not sutured along with some advocate that the closure should be done directly under vision.[7] Apart from these various other methods and techniques are used for prevention such as port plugs, mesh placement, Deschamps needle, identification of yellow island for ancillary ports, and paramedian entry.[8] Treatment of port-site hernia is closure of the defect after assessing the viability of bowel with sutures or with mesh as the situation demands; however, no definite cutoff for the size of defect for mesh placement has been established as of now. Due to the paucity of studies, level of evidence, and small sample size on this topic, no standardized guidelines are there at present for prevention and treatment.[11]


  Conclusion Top


The occurrence of laparoscopic incisional port-site hernia is low; however, the consequences of this hernia can be devastating, so every diligent effort should be made by the operating surgeon to avoid it. The dilemma still exists regarding the pathogenesis, preventive closure of larger ports, and the optimum technique for tackling the port-site hernia due to a lack of high-level evidence. To end these logomachies, we need comprehensive thought and research to find the missing links and form standardized guidelines to deal these issues.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fear RE. Laparoscopy: A valuable aid in gynaecological diagnosis. Obstet Gynaecol 1968;31:297-309.  Back to cited text no. 1
    
2.
Maio A, Ruchman RB. CT diagnosis of postlaparoscopic hernia. J Comput Assist Tomogr. 1991;15:1054-5. doi: 10.1097/00004728-199111000-00032. PMID: 1834705.  Back to cited text no. 2
    
3.
Crist DW, Gadacz TR. Complications of laparoscopic surgery. Surg Clin North Am 1993;73:265-89.  Back to cited text no. 3
    
4.
Hussain A, Mahmood H, Singhal T, Balakrishnan S, Nicholls J, El-Hasani S. Long-term study of port-site incisional hernia after laparoscopic procedures. JSLS 2009;13:346-9.  Back to cited text no. 4
    
5.
Khurshid N, Chung M, Horrigan T, Manahan K, Geisler JP. 5-millimeter trocar-site bowel herniation following laparoscopic surgery. JSLS 2012;16:306-10.  Back to cited text no. 5
    
6.
Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004;139:1248-56.  Back to cited text no. 6
    
7.
Matthews BD, Heniford BT, Sing RF. Preperitoneal Richter hernia after a laparoscopic gastric bypass. Surg Laparosc Endosc Percutan Tech 2001;11:47-9.  Back to cited text no. 7
    
8.
Jamadar NS, Ray DK, Das S. Port site hernia in laparoscopic surgery: Way to prevent it. Hellenic Journal of Surgery 2016;88:6, 402-4.  Back to cited text no. 8
    
9.
Zhu YP, Liang S, Zhu L, Sun ZJ, Lang JH. Trocar-site hernia after gynecological laparoscopic surgery: A 20-year, single-center experience. Chin Med J (Engl) 2019;132:2677-83.  Back to cited text no. 9
    
10.
Nofal MN, Yousef AJ, Hamdan FF, Oudat AH. Characteristics of trocar site hernia after laparoscopic cholecystectomy. Sci Rep 2020;10:2868.  Back to cited text no. 10
    
11.
Lambertz A, Stüben BO, Bock B, Eickhoff R, Kroh A, Klink CD, et al. Port-site incisional hernia - A case series of 54 patients. Ann Med Surg (Lond) 2017;14:8-11.  Back to cited text no. 11
    
12.
Tarnay CM, Glass KB, Munro MG. Incision characteristics associated with six laparoscopic trocar-cannula systems: A randomized, observer-blinded comparison. Obstet Gynecol 1999;94:89-93.  Back to cited text no. 12
    
13.
Pamela D, Roberto C, Francesco LM, Umberto M, Carla M, Vincenzo N, et al. Trocar site hernia after laparoscopic colectomy: A case report and literature review. ISRN Surg 2011. p. 7. Article ID: 725601, 2011. https://doi.org/10.5402/2011/725601.  Back to cited text no. 13
    
14.
Boone JD, Fauci JM, Barr ES, Estes JM, Bevis KS. Incidence of port site hernias and/or dehiscence in robotic-assisted procedures in gynecologic oncology patients. Gynecol Oncol 2013;131:123-6.  Back to cited text no. 14
    
15.
Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: A qualitative systematic review. Hernia 2011;15:113-21.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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