Postoperative bowel herniation in a 5-mm nonbladed trocar site.

BACKGROUND: Incisional hernias are a rare complication of laparoscopic surgery, with a reported incidence of <1%. CASE REPORT: We describe a case of bowel herniation and strangulation involving a 5-mm trocar site.
CONCLUSION: Although there is growing literature supporting fascial closure of abdominal port sizes ≥ 10 mm, there is sparse data to suggest closure of 5-mm port sites. Our case illustrates that in appropriate clinical scenarios, the possibility of a strangulated hernia involving a 5-mm port site warrants consideration.

INTRODUCTION

Complications from laparoscopic surgery occur in 0.1% to 10% of procedures. The most common complications are vascular and bowel injuries.[1] Incisional hernias are a rare complication of laparoscopic surgery, with a reported incidence of <1%. Most complications arise in trocar sites >10mm.[2] We describe a case of bowel herniation and strangulation involving a 5-mm trocar site.

CASE REPORT

GM is a 63-year-old woman initially treated in 1998 for ductal carcinoma in situ of the left breast with lumpectomy and local radiation therapy. In 2006, she developed a pleural effusion that subsequently revealed recurrent metastatic breast cancer. The recurrence was successfully treated with an aromatase inhibitor. She had no evidence of disease until surveillance PET/CT scan in December 2008 showed hypermetabolic nodules in the left peri-rectal and retrocaval areas. CT-guided biopsy of the left pelvic nodule demonstrated a high-grade adenocarcinoma consistent with recurrent breast cancer. She underwent a laparoscopic bilateral salpingo-oophorectomy and right paracaval lymph node biopsy. An infraumbilical nonbladed 10-mm trocar (Ethicon Endo-Surgery) and two 5-mm nonbladed trocars were inserted in the right and left lower quadrants along the mid-axillary line. A 5-cm soft-tissue mass was visualized arising from the fimbriated end of the left fallopian tube with no evidence of adenopathy or carcinomatosis. All specimens were removed through the umbilical port site by using endoscopic bags. The patient tolerated the procedure well with an operative time of 90 minutes and estimated blood loss of 10 mL. She was discharged home in stable condition.

Over the next 24 hours, she developed abdominal pain over the right incision accompanied by nausea and vomiting. She presented to the emergency department on postoperative day 1. On examination, a prominent 5-cm mass at the right lower quadrant trocar site was palpable with minimal tenderness. CT scan of the abdomen and pelvis revealed a small bowel herniation through the right trocar site. The fascial defect measured 15.93 mm in diameter ().

Computed tomographic scan demonstrating bowel herniation.

Laparoscopic exploration demonstrated multiple dilated loops of small bowel with a transition point at the right lower quadrant fascial defect. The skin incision over the trocar site was extended to reveal a 2.5-cm fascial defect. A 20-cm loop of strangulated ischemic bowel was in the subcutaneous space. The necrotic bowel was resected leaving an ample side-to-side anastomosis by utilizing a staple technique. Zero Prolene sutures reapproximated the fascial defect to create a tension-free closure. An adynamic ileus complicated the postoperative course but responded to conservative medical management. The patient was discharged 10 days after her second surgery tolerating a regular diet. Final pathology displayed a primary serous fallopian tube adenocarcinoma.

DISCUSSION

Advancement of laparoscopic equipment and surgical techniques has made minimally invasive surgery feasible in increasing numbers of clinical scenarios that previously required laparotomy. Laparoscopy has many advantages over laparotomy, such as less pain, smaller incisions, shorter recovery time and hospital stay, decreased blood loss, and faster return of bowel function.[3] The understanding of the risks involved with laparoscopic surgery has amplified with the increased volume. Conditions that increase the risk of complications include previous surgeries, extensive bowel distention, endometriosis, pelvic inflammatory disease, and cardiopulmonary disease.[4,5]

The reported incidence of trocar-site hernia in diagnostic laparoscopic procedures is approximately 0.2%. These hernias largely occur at the umbilical port site. Kadar et al[6] reviewed 3560 operative gynecologic laparoscopies to determine the incidence of incisional hernias. They found 6 incisional hernias (0.17%), all at extraumbilical sites occurring in 10-mm and 12-mm trocars. Based on these findings, the authors recommended fascial closure for only extraumbilical port sites >10 mm.

In 1994, Montz et al[7] published results of a large survey from the American Association of Gynecologic Laparoscopists, regarding their experience with laparoscopic trocar-site hernias. Of approximately 4 385 000 reported laparoscopic procedures, there were 933 hernias yielding an incidence of 0.021%. Interestingly, they reported 23 hernias (2.7%) that arose in port sites <8 mm in size. Although inherently biased, this survey was the first to estimate the incidence of trocar-site hernia for port sizes <8 mm. Since 1994, there have been a few case reports describing 5-mm port-site hernias presenting with bowel incarceration or small bowel obstruction. Nezhat et al[8] examined 5 300 laparoscopies, 11 of which were complicated by incisional hernia (incidence of 0.2%). Of the 11 hernias, 5 (45%) occurred at 5-mm trocar sites, leading the authors to suggest routine fascial closure of ports >10 mm and of 5-mm ports with extensive operative manipulation. Few case reports describe 5-mm port-site hernias presenting with bowel incarceration or obstruction but suggest routine fascial closure of 5-mm ports with extensive operative manipulation.

Tonouchi et al[9] examined pathogenesis and clinical manifestations of trocar-site hernia. They determined that a large trocar size, leaving the fascial defect open, and stretching the port site were all risk factors for postoperative hernia. Additionally, the authors examined the timing of presentation, classifying the hernias as early and late onset. The early onset group developed symptoms immediately after the operation (16/21, 76.2%) and mostly presented with symptoms of small bowel obstruction. The defect in this group was characterized by dehiscence of the anterior and posterior fascial plane and peritoneum. The late-onset group developed symptoms several months after surgery (median of 5.5 months) and presented with a distended abdomen (28/32, 87.5%) without small bowel obstruction. Tonouchi et al[9] also advocated for fascial closure in ports >10 mm and for 5-mm ports that had been extensively manipulated.

The advancement in laparoscopic equipment has included the development of nonbladed trocars that utilize a muscle and fascia separating technique. Most of the literature is in general surgery gastric bypass procedures. Liu et al[10] examined 180 laparoscopic nonbladed trocar insertions, including 110 10-mm and 12-mm ports where the fascial defects were not closed. On removal of the large trocar ports, the fascial defect was noted to be <6 mm to 8 mm, and the muscles of the abdominal wall covered the defect. The anterior and posterior fascial defects did not align. At a median follow-up of 11 months, none of the patients had developed a hernia. Similarly, Johnson et al[11] with the VersaStep and Rosenthal et al[12] with the Endopath demonstrated comparable results in larger patient populations (747 and 849, respectively). The former had 1 494 12-mm and 2 241 5-mm trocars, none of which had a hernia despite lack of suture closure. In 3 744 12-mm and 5-mm trocar placements, Rosenthal et al[12] found only 2 trocar-site hernias (0.2%). The authors concluded that the blunt-tipped tissue-separating trocar avoids tearing and cutting that occurs with previously used cutting trocar. This obviates the need for time-consuming fascial closure and decreases the risk of incisional hernia development.

The present case is a unique addition to the literature, because the hernia was found in a 5-mm port site that had been utilized only for grasping and cutting tissue with a Harmonic scalpel and not for specimen retrieval. The fascial defect was most likely due to weak fascial tissue, potentially secondary to malignancy. Furthermore, the initial small fascial defect was probably extended by the herniated bowel to reach the larger 2.5-cm dimension. Despite a relatively benign presentation, without evidence of bowel ischemia on physical examination or suggestive findings on CT scan, a large segment of necrotic small bowel required bowel resection. While incisional hernia following laparoscopy is a rare occurrence, growing literature supports fascial closure of port sizes ≥10m m. However, there remains sparse data supporting routine closure of 5-mm port sites secondary to the low reported incidence of herniation. The possibility of strangulated hernia in a 5-mm port site warrants consideration in the appropriate clinical scenario. Immediate surgical intervention may avoid the need for bowel resection and potentially life-threatening sepsis.