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L. Rebibo et al. / Surgery for Obesity and Related Diseases 11 (2015) 791–797
[11] Dhahri A, Verhaeghe P, Hajji H, et al. Sleeve gastrectomy: technique and results. J Visc Surg 2010;147(Suppl 5):e39–46. [12] Deguines JB, Qassemyar Q, Dhahri A, et al. Technique of open laparoscopy for supramesocolic surgery in obese patients. Surg Endosc 2010;24:2053–5. [13] Deguines JB, Verhaeghe P, Yzet T, Robert B, Cosse C, Regimbeau JM. Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure? Surg Obes Relat Dis 2013;9:660–6. [14] Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004;139:1248–56. [15] Swank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman WA. Systematic review of trocar-site hernia. Br J Surg 2012;99:315–23. [16] Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 2011;15: 113–21. [17] Chang WT, Yu FJ, Hsieh MY, et al. Laparoscopic cholecystectomy in aged patients. Hepatogastroenterology 2009;56:950–5. [18] Angioli R, Terranova C, De Cicco Nardone C, et al. A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial. Eur J Obstet Gynecol Reprod Biol 2013;171:339–42.
[19] Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;171:80–4. [20] Puzziferri N, Austrheim‐Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three‐year follow‐up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006;243: 181–8. [21] Sauerland S, Korenkov M, Kleinen T, Arndt M, Paul A. Obesity is a risk factor for recurrence after incisional hernia repair. Hernia 2004;8: 42–6. [22] Erdas E, Dazzi C, Secchi F, et al. Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: a long-term follow-up study. Hernia 2012;16:431–7. [23] Scozzari G, Zanini M, Cravero F, Passera R, Rebecchi F, Morino M. High incidence of trocar site hernia after laparoscopic or robotic Roux-en-Y gastric bypass. Surg Endosc. Epub 2014 May 2. [24] Pilone V, Di Micco R, Hasani A, et al. Trocar site hernia after bariatric surgery: our experience without fascial closure. Int J Surg. Epub 2014 May 23. [25] Del Junco M, Okhunov Z, Juncal S, Yoon R, Landman J. Evaluation of a novel trocar-site closure and comparison with a standard CarterThomason closure device. J Endourol 2014;28:814–8.
Editorial
Comment on: Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique Without a doubt, the prevalence of incisional hernias after laparoscopy is underestimated in the literature. This underestimation of port site hernias is for a multitude of reasons, including: subjective hernia evaluation, loss of follow-up, and inadequate long-term surveillance. In the morbidly obese population, most port site hernias are asymptomatic and undetectable on physical exam alone. This is likely a contributing factor for the low reported incidence of port site hernias in the morbidly obese population compared with the nonobese. What is the true incidence of port site hernias in patients undergoing metabolic and weight loss surgery? How should this influence our surgical technique? In this issue, Dr. Regimbeau et al. have sought to answer these questions [1]. They reviewed the computerized tomographic (CT) scans of 228 patients that had undergone laparoscopic sleeve gastrectomy (LSG) with an average time interval from operation to CT scan of 27 months. They found a clinically evident port site hernia in 2.2% of their study group, but an astonishing 18.8% port site hernia occurrence when evaluated by CT scan. When the interval from operation to CT scan was divided into quartiles, the group with the longest interval, 13 to 24 months after operation, had a 20% frequency of port site hernias, which is well above the commonly published rate of 0%–5.2% [2,3,4].
This study illustrates the fact that many port site hernias go undiagnosed because they are asymptomatic and hard to detect on physical exam. Unless routine follow-up with radiographic evaluation is performed, especially in the morbidly obese patient, the true incidence of port site hernias will be underreported. By having access to postoperative CT scans, Dr. Regimbeau et al. were able to demonstrate a much higher hernia rate [1]. Had they relied on patient symptoms and physical exam alone they would have reported a 2.2% port site hernia rate, similar to previously published studies. I congratulate the authors on confirming that the true hernia occurrence is much higher when radiographic evaluation is performed and modifying their practice based on these results. The study raises these questions: What is the clinical significance of an asymptotic port site hernia? How should this alter surgical technique? Surgical technique is at the center for affecting the development of port site hernias. In the study, 86% of the reported hernias occurred at the 12 mm epigastric port site, where a bladed trocar was used and no fascial closure was performed [1]. And yet there were no reported port site hernias at the 12 mm left lateral subcostal port site where an identical bladed trocar was used without fascial closure. This reaffirms the concept that port site location significantly affects the incidence of hernia
Trocar Site Hernia After Laparoscopic Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 791–797
formation. Trocars placed through the linea alba greatly increase the rate of hernia formation as seen in this study. Trocar size along with the degree of fascial disruption is also an important factor in determining port site hernia rates. Using an open laparoscopic technique, with placement of a 15 mm trocar and closure of the anterior and posterior fascia, resulted in a 1.8% port site hernia rate in this study [1]. Even with the best of closure techniques, anterior and posterior fascial closure, port site hernias cannot be completely avoided. The modifiable factors that influence port site hernia rates are port size, port location, trocar selection, and fascial closure. Smaller trocars cause less fascial disruption and result in a lower incidence of port site hernias [3,5]. Selecting the smallest feasible trocar reduces port site hernias. Trocar location with avoidance of the midline greatly reduces the incidence of port site hernias as noted in this study [1]. Trocar type influences the amount of fascial disruption and, therefore, the incidence of port site hernia as well. Cutting pyramidal trocars cause the greatest amount of fascial disruption while radially dilating trocars cause the least [6]. While fascial closure reduces the incidence of port site hernias it does not replace the need for proper location and trocar selection. Historically, it has been recommended to close all port sites where a Z10 mm trocar has been used [3,5]. With the advent of radially dilating trocars, this conventional practice has been challenged. Animal studies have shown that the amount of fascial disruption is significantly less with radially dilating trocar versus bladed trocars [6]. There are clinical studies showing no port site hernias when 12 mm radially dilating trocars were used without fascial closure [4,7]. Again, this may be an effect of underreported hernia occurrence from nonradiographic follow-up [8]. While morbid obesity significantly increases incisional hernia rates for midline laparotomies, it appears to be associated with decreased port site hernia rates [3]. It is unknown if this is from decreased detection on physical examination or if a thickened abdominal wall is protective for port site hernia formation. While I agree with the authors’ conclusion that port site hernias are underestimated in the literature, I believe that for most surgical techniques the actual occurrence rate is closer to 2% than their reported 18.8%. Most of their port site
797
hernias were from the epigastric trocar; I agree with their conclusion that a change in their surgical practice is needed. But I would argue that adding fascial closure to their epigastric port site would not be nearly as effective as moving the epigastric port site to another location away from the midline, reducing the port site from 12 mm to a smaller port, and switching from a bladed trocar to a radially dilating trocar. Port site fascial closure is a component of a much larger list of modifiable factors that influence port site hernia incidence. Disclosures Sources of funding: None. Lawrence E. Tabone, M.D. Assistant Professor of Surgery Department of Surgery West Virginia University References [1] Rebibo L, Dhahri A, Chivot C, et al. Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique. Surg Obes Relat Dis 2015;11(4):791–6. [2] Helgstrand F, Rosenberg J, Bisqaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 2011;15 (2):113–21. [3] Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surgeon 2011;9(4):218–24. [4] Johnson WH, Fecher AM, McMahon RL, et al. VersaStepTM trocar hernia rate in unclosed fascial defects in bariatric patients. Surg Endosc 2006;20(10):1584–6. [5] Montz FJ, Holschneider CH, Munro MG. Incisional hernia following laparoscopy: a surgery of the American Association of Gynecologic Laparoscopists. Obstet Gynecol 1994;84(5):881–4. [6] Shafer DM, Khajanchee MB, Wong J, Swanstrom LL. Comparison of five different abdominal access trocar systems: analysis of insertion force, removal force, and defect size. Surg Innov 2006;13(3):183–9. [7] Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study of radially expanding trocars in laparoscopic surgery. J Gastroinest Surg 2000;4(4):392–7. [8] Chiong E, Hegarty P, Davis J, et al. Port-site hernias occurring after the use of bladeless radially expanding trocars. Urology 2010;75 (3):574–80.
L. Rebibo et al. / Surgery for Obesity and Related Diseases 11 (2015) 791–797
[11] Dhahri A, Verhaeghe P, Hajji H, et al. Sleeve gastrectomy: technique and results. J Visc Surg 2010;147(Suppl 5):e39–46. [12] Deguines JB, Qassemyar Q, Dhahri A, et al. Technique of open laparoscopy for supramesocolic surgery in obese patients. Surg Endosc 2010;24:2053–5. [13] Deguines JB, Verhaeghe P, Yzet T, Robert B, Cosse C, Regimbeau JM. Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure? Surg Obes Relat Dis 2013;9:660–6. [14] Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004;139:1248–56. [15] Swank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman WA. Systematic review of trocar-site hernia. Br J Surg 2012;99:315–23. [16] Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 2011;15: 113–21. [17] Chang WT, Yu FJ, Hsieh MY, et al. Laparoscopic cholecystectomy in aged patients. Hepatogastroenterology 2009;56:950–5. [18] Angioli R, Terranova C, De Cicco Nardone C, et al. A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial. Eur J Obstet Gynecol Reprod Biol 2013;171:339–42.
[19] Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;171:80–4. [20] Puzziferri N, Austrheim‐Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three‐year follow‐up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006;243: 181–8. [21] Sauerland S, Korenkov M, Kleinen T, Arndt M, Paul A. Obesity is a risk factor for recurrence after incisional hernia repair. Hernia 2004;8: 42–6. [22] Erdas E, Dazzi C, Secchi F, et al. Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: a long-term follow-up study. Hernia 2012;16:431–7. [23] Scozzari G, Zanini M, Cravero F, Passera R, Rebecchi F, Morino M. High incidence of trocar site hernia after laparoscopic or robotic Roux-en-Y gastric bypass. Surg Endosc. Epub 2014 May 2. [24] Pilone V, Di Micco R, Hasani A, et al. Trocar site hernia after bariatric surgery: our experience without fascial closure. Int J Surg. Epub 2014 May 23. [25] Del Junco M, Okhunov Z, Juncal S, Yoon R, Landman J. Evaluation of a novel trocar-site closure and comparison with a standard CarterThomason closure device. J Endourol 2014;28:814–8.
Editorial
Comment on: Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique Without a doubt, the prevalence of incisional hernias after laparoscopy is underestimated in the literature. This underestimation of port site hernias is for a multitude of reasons, including: subjective hernia evaluation, loss of follow-up, and inadequate long-term surveillance. In the morbidly obese population, most port site hernias are asymptomatic and undetectable on physical exam alone. This is likely a contributing factor for the low reported incidence of port site hernias in the morbidly obese population compared with the nonobese. What is the true incidence of port site hernias in patients undergoing metabolic and weight loss surgery? How should this influence our surgical technique? In this issue, Dr. Regimbeau et al. have sought to answer these questions [1]. They reviewed the computerized tomographic (CT) scans of 228 patients that had undergone laparoscopic sleeve gastrectomy (LSG) with an average time interval from operation to CT scan of 27 months. They found a clinically evident port site hernia in 2.2% of their study group, but an astonishing 18.8% port site hernia occurrence when evaluated by CT scan. When the interval from operation to CT scan was divided into quartiles, the group with the longest interval, 13 to 24 months after operation, had a 20% frequency of port site hernias, which is well above the commonly published rate of 0%–5.2% [2,3,4].
This study illustrates the fact that many port site hernias go undiagnosed because they are asymptomatic and hard to detect on physical exam. Unless routine follow-up with radiographic evaluation is performed, especially in the morbidly obese patient, the true incidence of port site hernias will be underreported. By having access to postoperative CT scans, Dr. Regimbeau et al. were able to demonstrate a much higher hernia rate [1]. Had they relied on patient symptoms and physical exam alone they would have reported a 2.2% port site hernia rate, similar to previously published studies. I congratulate the authors on confirming that the true hernia occurrence is much higher when radiographic evaluation is performed and modifying their practice based on these results. The study raises these questions: What is the clinical significance of an asymptotic port site hernia? How should this alter surgical technique? Surgical technique is at the center for affecting the development of port site hernias. In the study, 86% of the reported hernias occurred at the 12 mm epigastric port site, where a bladed trocar was used and no fascial closure was performed [1]. And yet there were no reported port site hernias at the 12 mm left lateral subcostal port site where an identical bladed trocar was used without fascial closure. This reaffirms the concept that port site location significantly affects the incidence of hernia
Trocar Site Hernia After Laparoscopic Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 791–797
formation. Trocars placed through the linea alba greatly increase the rate of hernia formation as seen in this study. Trocar size along with the degree of fascial disruption is also an important factor in determining port site hernia rates. Using an open laparoscopic technique, with placement of a 15 mm trocar and closure of the anterior and posterior fascia, resulted in a 1.8% port site hernia rate in this study [1]. Even with the best of closure techniques, anterior and posterior fascial closure, port site hernias cannot be completely avoided. The modifiable factors that influence port site hernia rates are port size, port location, trocar selection, and fascial closure. Smaller trocars cause less fascial disruption and result in a lower incidence of port site hernias [3,5]. Selecting the smallest feasible trocar reduces port site hernias. Trocar location with avoidance of the midline greatly reduces the incidence of port site hernias as noted in this study [1]. Trocar type influences the amount of fascial disruption and, therefore, the incidence of port site hernia as well. Cutting pyramidal trocars cause the greatest amount of fascial disruption while radially dilating trocars cause the least [6]. While fascial closure reduces the incidence of port site hernias it does not replace the need for proper location and trocar selection. Historically, it has been recommended to close all port sites where a Z10 mm trocar has been used [3,5]. With the advent of radially dilating trocars, this conventional practice has been challenged. Animal studies have shown that the amount of fascial disruption is significantly less with radially dilating trocar versus bladed trocars [6]. There are clinical studies showing no port site hernias when 12 mm radially dilating trocars were used without fascial closure [4,7]. Again, this may be an effect of underreported hernia occurrence from nonradiographic follow-up [8]. While morbid obesity significantly increases incisional hernia rates for midline laparotomies, it appears to be associated with decreased port site hernia rates [3]. It is unknown if this is from decreased detection on physical examination or if a thickened abdominal wall is protective for port site hernia formation. While I agree with the authors’ conclusion that port site hernias are underestimated in the literature, I believe that for most surgical techniques the actual occurrence rate is closer to 2% than their reported 18.8%. Most of their port site
797
hernias were from the epigastric trocar; I agree with their conclusion that a change in their surgical practice is needed. But I would argue that adding fascial closure to their epigastric port site would not be nearly as effective as moving the epigastric port site to another location away from the midline, reducing the port site from 12 mm to a smaller port, and switching from a bladed trocar to a radially dilating trocar. Port site fascial closure is a component of a much larger list of modifiable factors that influence port site hernia incidence. Disclosures Sources of funding: None. Lawrence E. Tabone, M.D. Assistant Professor of Surgery Department of Surgery West Virginia University References [1] Rebibo L, Dhahri A, Chivot C, et al. Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique. Surg Obes Relat Dis 2015;11(4):791–6. [2] Helgstrand F, Rosenberg J, Bisqaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 2011;15 (2):113–21. [3] Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surgeon 2011;9(4):218–24. [4] Johnson WH, Fecher AM, McMahon RL, et al. VersaStepTM trocar hernia rate in unclosed fascial defects in bariatric patients. Surg Endosc 2006;20(10):1584–6. [5] Montz FJ, Holschneider CH, Munro MG. Incisional hernia following laparoscopy: a surgery of the American Association of Gynecologic Laparoscopists. Obstet Gynecol 1994;84(5):881–4. [6] Shafer DM, Khajanchee MB, Wong J, Swanstrom LL. Comparison of five different abdominal access trocar systems: analysis of insertion force, removal force, and defect size. Surg Innov 2006;13(3):183–9. [7] Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study of radially expanding trocars in laparoscopic surgery. J Gastroinest Surg 2000;4(4):392–7. [8] Chiong E, Hegarty P, Davis J, et al. Port-site hernias occurring after the use of bladeless radially expanding trocars. Urology 2010;75 (3):574–80.
