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Port site herniation of the small bowel following laparoscopy-assisted distal gastrectomy: a case report
© Itoh et al; licensee BioMed Central Ltd. 2008
Received: 30 July 2007
Accepted: 14 February 2008
Published: 14 February 2008
Port-site herniation is a rare but potentially dangerous complication after laparoscopic surgery. Closure of port sites, especially those measuring 10 mm or more, has been recommended to avoid such an event.
We herein report the only case of a port site hernia among a series 52 consecutive cases of laparoscopy-assisted distal gastrectomy (LADG) carried out by our unit between July 2002 and March 2007. In this case the small bowel herniated and incarcerated through the port site on day 4 after LADG despite closure of the fascia. Initial manifestations experienced by the patient, possibly due to obstruction, and including mild abdominal pain and nausea, occurred on the third day postoperatively. The definitive diagnosis was made on day 4 based on symptoms related to leakage from the duodenal stump, which was considered to have developed after severe obstruction of the bowel. Re-operation for reduction of the incarcerated bowel and tube duodenostomy with peritoneal drainage were required to manage this complication.
We present this case report and review of literature to discuss further regarding methods of fascial closure after laparoscopic surgery.
Bowel herniation through the fascial defect created by the entry of trocars is now recognized as a rare but potentially serious complication of laparoscopic surgery . Although port site herniation is an infrequent complication, there are still some reports of port site herniation after these procedures, even with closure of trocar sites[1, 2]. The following report describes a case of a trocar site hernia that evolved into leakage from the duodenal stump after laparoscopy-assisted distal gastrectomy (LADG). Progression occurred because of complete obstruction of the incarcerated bowel after a Roux-en-Y reconstruction. We describe the significance of complete closure of the fascial defect at the trocar site including the peritoneum in the prevention of this condition, as well as the importance of early diagnosis to avoid serious subsequent events.
Port-site herniation, which is one of the major complications after laparoscopic procedures , sometimes develops into serious complications, such as bowel obstruction due to incarceration into the fascial defect at the port site. Boughey et al. have reported four cases of Richter's hernia that occurred at a port site after laparoscopic surgery . They reviewed previous reports and found the incidence to be 0.2 to 3%. A report describes the incidence of hernia as 0.23% for 10-mm trocar use, rising to 3.1% for the 12-mm trocar  suggesting that the wound created by a larger port carries a greater risk of herniation. Most surgeons now routinely close the fascia of port sites to prevent this complication . According to previous reports, port site herniation apparently happens more often with the use of bladed type trocars than non-bladed type trocars . Indeed, Kolata demonstrated that the wounds made by the non-bladed trocar were narrower than those created by cutting tip trocars in a pig experimental model . Several reports even concluded that port sites created by non-bladed trocars do not require fascial closure . However, the current case suggests that thick preperitoneum is a potential space that allows for the development of bowel herniation even with the use of non-bladed type trocars. A previous report also described port-site herniation, despite the closure of the superficial layer of the fascial defect . The current case did not demonstrate any of the risk factors suggested previously ; 1) enlargement of a port site to remove specimen; 2) glucose intolerance; 3) obesity; or 4) extensive manipulation of the trocar during relatively prolonged surgical duration, which might have enlarged the trocar site and thus induced bowel herniation. Therefore, we recommend closing the fascial defect, including the peritoneum, especially if the trocar size is more than 10-mm and in the presence of any of the risk factors described above. However, it is sometimes difficult to completely close the defect, including the peritoneum, especially in obese patients. Shaher reviewed different wound closure techniques by a literature search . In this review, old methods using classical instruments including Deschamps needle are also useful as well as special wound devices designed for port site closure. Elashry et al. described a prospective randomized study demonstrating that the Carter-Thomason device was faster and resulted in fewer port-closure-related complications among eight different techniques tested . Insertion of a SURGICEL plug into the muscular layer of trocar wounds has also been proposed by Chiu et al . Alternatively, tangential insertion of a trocar through the abdominal wall might be effective in reducing the size of fascial defects. Moreover, recent publications have demonstrated that radially expanding type trocars could be useful to avoid the necessity of closing the fascial defect .
Symptoms of trocar-site herniation vary depending on the severity of bowel obstruction. Mild symptoms such as slight nausea and vague abdominal pain, both of which are most frequently seen in the early normal postoperative course after abdominal surgery, could be the first and only complaints at the early stage of this complication. Thus, the diagnosis may be delayed. In our case, mild abdominal pain with general malaise might have been symptoms related to the early stage of the onset. Abdominal CT showing the enlarged duodenum also suggested that leakage from the duodenal stump occurred due to the obstruction of the distal bowel. Thus, severe complication might have been avoided, if early diagnosis had been made. Although the benefit of Roux-en-Y is apparent , the duodenal stump could be vulnerable to leakage due to increased intrabowel pressure. Therefore, careful management of the postoperative course is warranted, especially after procedures involving division of the bowel such as LADG. Moreover, special attention should be paid in patients with risk factors for port site hernia such as obesity, aggressive manipulation through the port sites, and prolonged surgery.
Port-site herniation is a potentially dangerous complication after laparoscopic procedures. Careful management of the postoperative course is recommended especially for patients with risk factors such as obesity and extensive manipulation of the trocar during prolonged surgical duration.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors thank the patient for permitting the publication of the data regarding his case.
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