Background

Port site hernias are a recognized complication of laparoscopic surgery and carry a high risk of strangulation because of the small size of the defect involved. Most hernias occur in trocar sites that are larger than 10 mm. This has resulted in the accepted practice that fascial defects larger than 10 mm are closed, incorporating the peritoneum and fascia, whereas defects less than 10 mm are not closed.

Results

We report a port site hernia at a 5-mm port site in a 90-year-old woman after ventral rectoplexy. A systematic review of literature found 27 cases of 5-mm port site herniation: 10 cases in general surgery and 17 cases in gynecological surgery.

Conclusion

The possibility of herniation through 5-mm port sites should be known to avoid a delay in recognition, diagnosis, and treatment.

The incidence of trocar site hernias ranges from 0.65% to 2.8%.1  The rates are related to trocar size.2  A meta-analysis of port site hernias in gastrointestinal surgery found that 18 hernias occurred in 1780 port sites larger than 10 mm, whereas no hernias occurred at the 4444 ports sites smaller than 10 mm.3  It is widely accepted that it is not necessary to close fascial defects in adults in port sites <10 mm.4  We present a case report of a 5-mm trocar site hernia.

A 90-year-old woman underwent ventral rectoplexy after a 2-week history of full-thickness rectal prolapse. A 10–12 Hassan umbilical port was inserted, followed by three 5-mm ports in the right upper quadrant, left flank, and suprapubic regions. There was extensive adhesionolysis (secondary to previous midline exploratory laparotomy for appendicitis and laparoscopic-assisted vaginal hysterectomy). The total operative time was 120 minutes. The 10- to 12-mm port site fascia was closed using 1-0 Vicryl with a Karta Thompson laparoscopic suture passer, and the anterior recuts sheath was closed with interrupted 1-0 Maxon sutures. The 5-mm incisions were not closed at the fascial level. All sites were closed using INSORB 3-0 monocryl subcuticular sutures. The patient's recovery was unremarkable.

As an inpatient, at postoperative day 5, the patient reported abdominal pain and vomiting and had not opened her bowels in the preceding 24 hours. On examination, she was afebrile, with a distended abdomen and a tender palpable mass at her left flank port site. A computed tomography scan was performed, which suggested a small bowel obstruction from an incarcerated hernia in the left iliac fossa (Figs. 1 and 2). An emergency laparotomy identified the hernia, and the defect was enlarged transversely. The erythematous, not edematous, bowel was reduced, and the hernial orifice closed with 1-0 interrupted mattress sutures Polydioxanone (PDS), mass closure of abdominal wall, and subcuticular INSORB 3-0 monocryl sutures. The patient was admitted to the intensive care unit postoperatively for 3 days and then discharged to the ward for postsurgical optimization before her return to independent living.

Fig. 1

Axial computer topography images of the patient on postoperative day 5. A hernia can be visualized in the left iliac fossa at her left flank laparoscopic port site.

Fig. 1

Axial computer topography images of the patient on postoperative day 5. A hernia can be visualized in the left iliac fossa at her left flank laparoscopic port site.

Fig. 2

Sagittal computer topography images of the patient on postoperative day 5. A hernia can be visualized in the left iliac fossa at her left flank laparoscopic port site.

Fig. 2

Sagittal computer topography images of the patient on postoperative day 5. A hernia can be visualized in the left iliac fossa at her left flank laparoscopic port site.

A literature search was conducted in Ovid and Cochrane databases using the following search strategy: ((Port site hernia) OR (Laparoscopic port hernia) OR (trocar site hernia)) AND ((5-mm) OR (5mm) OR (five mm)). The date last searched was 29 May 2016. Reference lists of relevant studies were searched by hand to identify additional publications. Studies were excluded if they were not written in English or did not specify port size. Studies included reported laparoscopic port site hernias in an adult population.

Data were extracted on the surgical specialty, type of operation, port size and type where available, port site, patient characteristics (age, body mass index), time from surgery to hernia presentation, presence of organ evisceration in hernia, management of the hernia, and any comments on the case.

Databases and reference lists searched yielded 358 articles, and the full text of 105 studies were examined. Based on the inclusion and exclusion criteria, 20 studies were included (Tables 13). One study was a retrospective review, 1 was a prospective cohort study, and the remaining 18 were case reports.

Table 1

General surgery case reports

General surgery case reports
General surgery case reports
Table 2

Gynecological surgery case reports

Gynecological surgery case reports
Gynecological surgery case reports
Table 3

Original studies

Original studies
Original studies

There were 27 cases of 5-mm trocar site hernias. There were 10 cases in general surgery: 9 case reports and 1 case in a prospective cohort trial. There were 17 cases in gynecological surgery: 12 case reports and 5 cases in a retrospective cohort trial.

Surgical factors contributing to the development of hernias include the number of trocars, trocar size, location, trocar type, manipulation, the duration of procedure, drain positioning through the port sites, entry, and closure techniques.2,5  Additionally, patient factors contributing to an increased rate of trocar site herniation's may include preexisting fascial defects, obesity, and surgical site infections.5 

Extensive manipulation of trocar sites may widen the port site incision fascia and peritoneum beyond the initial length. Stretching may occur secondary to specimen removal, multiple reinsertions of the sheath, increased force and torque on the fascia, and prolonged operative time. The retrospective review by Nezhat et al6  noted that each of the 5 surgeries resulting in trocar site hernias were associated with surgical difficulties. For example, extensive adhesions, as seen in our case, required extensive manipulation from the trocar sites.

Laparoscopic port site herniation is a preventable cause of morbidity that requires a second, often emergent (or unplanned), surgical procedure to repair. All fascial defects larger than or equal to 10 mm should be closed at the fascial level. Smaller defects may require closure in certain circumstances to prevent subsequent herniation; in particular, where port sites have been subjected to additional unanticipated mechanical stress throughout the procedure. After laparoscopic procedures, patients reporting postoperative incisional swelling or gastrointestinal obstructive symptoms should be expediently evaluated for possible bowel herniation, regardless of port size used to avoid delays in diagnosis and treatment.

Observational case report ethics approval from an ethics committee or institutional review board was not required.

1. 
Tonouchi
H,
Ohmori
Y,
Kobayashi
M,
Kusunoki
M.
Trocar site hernia
.
Arch Surg
2004
;
139
(11)
:
1248
1256
2. 
Yamamoto
M,
Minikel
L,
Zaritsky
E.
Laparoscopic 5-mm trocar site herniation and literature review
.
JSLS
2011
;
15
(1)
:
122
126
3. 
Owens
M,
Barry
M,
Janjua
AZ,
Winter
DC.
A systematic review of laparoscopic port site hernias in gastrointestinal surgery
.
Surgeon
2011
;
9
(4)
:
218
224
4. 
Reardon
PR,
Preciado
A,
Scarborough
T,
Matthews
B,
Marti
JL.
Hernia at 5-mm laparoscopic port site presenting as early postoperative small bowel obstruction
.
J Laparoendosc Adv Surg Tech A
1999
;
9
(6)
:
523
525
5. 
Dulskas
A,
Lunevicius
R,
Stanaitis
J.
A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy
.
J Minim Access Surg
2011
;
7
(3)
:
187
189
6. 
Nezhat
C,
Nezhat
F,
Seidman
DS,
Nezhat
C.
Incisional hernias after operative laparoscopy
.
J Laparoendosc Adv Surg Tech A
1997
;
7
(2)
:
111
115
7. 
Abdel-Halim
MRE,
Higgs SM, Niayesh MH. Early port site hernia causing small bowel obstruction after laparoscopic appendicectomy
.
Grand Rounds
2007
;
7
:
64
66
8. 
Coda
A,
Bossotti
M,
Ferri
F,
Mattio
R,
Ramellini
G,
Poma
A
et al
Incisional hernia and fascial defect following laparoscopic surgery
.
Surg Laparosc Endosc Percutan Tech
2000
;
10
(1)
:
34
38
9. 
Fleming
F,
Winter
D.
Images in surgery. Richter's hernia at a 5-mm laparoscopic port site
.
Surgery
2009
;
146
(3)
:
523
10. 
Matter
I,
Nash
E,
Abrahamson
J,
Eldar
S.
Incisional hernia via a lateral 5 mm trocar port following laparoscopic cholecystectomy
.
Isr J Med Sci
1996
;
32
(9)
:
790
791
11. 
Mehmet
EY.
Meckel's diverticulum as a leading point of early onset-type hernia through a 5-mm trocar site incision
.
Surg Pract
2014
;
18
(3)
:
149
151
12. 
Plaus
WJ.
Laparoscopic trocar site hernias
.
J Laparoendosc Surg
1993
;
3
(6)
:
567
570
13. 
Ravichandran
K,
Velan
MS,
Karthik
M,
Ajmal
IT,
Venkatesan
KP.
A case report of incisional hernia through a 5mm suprapubic port site following laparoscopic appendicectomy
.
J Evol Med Dental Sci
2014
;
3
(73)
:
15448
15642
14. 
Bergemann
JL,
Hibbert
ML,
Harkins
G,
Narvaez
J,
Asato
A.
Omental herniation through a 3-mm umbilical trocar site: unmasking a hidden umbilical hernia
.
J Laparoendosc Adv Surg Tech A
2001
;
11
(3)
:
171
173
15. 
Eltabbakh
GH.
Small bowel obstruction secondary to herniation through a 5-mm laparoscopic trocar site following laparoscopic lymphadenectomy
.
Eur J Gynaecol Oncol
1999
;
20
(4)
:
275
276
16. 
Huang
M,
Musa
F,
Castillo
C,
Holcomb
K.
Postoperative bowel herniation in a 5-mm nonbladed trocar site
.
JSLS
2010
;
14
(2)
:
289
291
17. 
Khurshid
N,
Chung
M,
Horrigan
T,
Manahan
K,
Geisler
JP.
5-millimeter trocar-site bowel herniation following laparoscopic surgery
.
JSLS
2012
;
16
(2)
:
306
310
18. 
Kanis
MJ,
Momeni
M,
Zakashansky
K,
Chuang
L,
Hayes
MP.
Five-millimeter balloon trocar site herniation: report of two cases and review of literature
.
J Minim Invasive Gynecol
2013
;
20
(5)
:
723
726
19. 
Moreaux
G,
Estrade-Huchon
S,
Bader
G,
Guyot
B,
Heitz
D,
Fauconnier
A
et al
Five-millimeter trocar site small bowel eviscerations after gynecologic laparoscopic surgery
.
J Minim Invasive Gynecol
2009
;
16
(5)
:
643
645
20. 
Sayasneh
ANA,
Abdel-Rahman
H.
A case report of incisional hernia through a 5-mm lateral port site following laparascopic right ovarian cystectomy
.
Gyncecol Surg
2011
;
8
:
227
230
21. 
Ankur Thapar
BK,
Pyper
R,
Woods
W.
5 mm port site hernia causing small bowel obstruction
.
Gynecol Surg
2010
;
7
:
71
73
22. 
Toub
DB,
Campion
MJ.
Omental herniation through a 5-mm laparoscopic cannula site
.
J Am Assoc Gynecologic Laparoscopists
1994
;
1
(4)
:
413
414
23. 
Nassar
AH,
Ashkar
KA,
Rashed
AA,
Abdulmoneum
MG.
Laparoscopic cholecystectomy and the umbilicus
.
Br J Surg
1997
;
84
(5)
:
630
633