Surgery for Obesity and Related Diseases 11 (2015) 791–797
Original article
Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique Lionel Rebibo, M.D.a,c, Abdennaceur Dhahri, M.D.a,c, Cyril Chivot, M.D.b,c, Cosse Cyril, Ph.Da,c, Thierry Yzet, M.D., Ph.Db,c, Jean-Marc Regimbeau, M.D., Ph.D.a,c,* a
Department of Digestive Surgery, Amiens University Hospital, Amiens, France b Department of Radiology, Amiens University Hospital, Amiens, France c Jules Verne University of Picardie, Amiens, France Received August 31, 2014; accepted November 30, 2014
Abstract
Background: Obesity is recognized as a risk factor for trocar site hernia (TSH) after laparoscopic surgery. Some recent studies have reported a TSH rate after bariatric surgery ranging from 0% to 1.6% using clinical evaluation and may underestimate the TSH rate. The objective of this study was to evaluate the TSH rate after sleeve gastrectomy (SG) by abdominal computed tomography (CT) scan. Methods: A retrospective review of all patients who underwent first-line SG and abdominal CT scan between March 2004 and February 2014 was performed. The primary endpoint was the incidence of TSH. Secondary endpoints were the site of TSH, the TSH rate with open laparoscopy using the authors’ technique, and risk factors for TSH after SG. Results: During the period study, 1108 patients underwent first-line SG, including 10 cases of conversion to laparotomy (excluded from the present analysis). Of the remaining patients, 228 had abdominal CT scan (20.7%), with a mean age of 45.1 years (18–68 yr) and a mean BMI of 47.6 kg/ m2 (33–75.4 kg/m2). The median time interval between SG and CT scan was 27 months (3–92 mo). CT scan revealed 44 TSH in 43 patients (18.8%). The site of the TSH was epigastric (16.6%), open laparoscopy (1.7%), right subcostal margin (0.8%), with no TSH in the left subcostal margin. In patients with 41 year of follow-up, the TSH rate was 19.7%. Conclusion: The TSH rate after bariatric surgery is underestimated. The authors’ open laparoscopy technique is a reliable technique with a low TSH rate. In the light of these results, the epigastric trocar site is systematically closed at the end of SG. (Surg Obes Relat Dis 2015;11:791–797.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Sleeve gastrectomy; Abdominal CT scan; Trocar site hernia; Open laparoscopy
The use of laparoscopy has promoted the growth of bariatric surgery, with increasing numbers of surgical procedures performed all over the world. Sleeve gastrectomy (SG) is currently the surgical procedure most commonly performed in France because of its relative * Correspondence: Jean-Marc Regimbeau, M.D., Ph.D., Department of Digestive Surgery, Hôpital Nord, CHU d'Amiens, Place Victor Pauchet, F80054 Amiens cedex 01, France. E-mail: [email protected]
simplicity, its low complication rate [1], and good results in terms of weight loss with 45 years of follow-up [2,3]. However, trocar site hernia (TSH) is a long-term complication that is not specific to SG. The risk factors for incisional hernia include surgical wound infections, age, trocar site (close to the linea alba), and the size of the trocars used (410 mm diameter) [4,5]. Obesity is also a recognized risk factor for TSH after laparoscopic surgery [6]. However, some recent studies have reported lower TSH rates after bariatric surgery than
http://dx.doi.org/10.1016/j.soard.2014.11.028 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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L. Rebibo et al. / Surgery for Obesity and Related Diseases 11 (2015) 791–797
after colorectal surgery [7]. Other series have also reported TSH rates after bariatric surgery ranging from 0% to 1.6% [8,9]. The problem with such series is that evaluation of TSH rate is purely clinical, and clinical evaluation of incisional hernia (particularly TSH) can sometimes be difficult in obese patients, despite weight loss after surgery. The objective of this study was to evaluate the TSH rate after laparoscopic SG by abdominal computed tomography (CT) scan and to evaluate the incisional hernia rate of the authors’ open laparoscopy technique for obese patients. Methods Population From March 2004 to February 2014, all patients undergoing abdominal CT scan at least 3 months after SG procedures were included in the study (n = 228), which therefore consisted of a retrospective review of a prospective database in a group of patients having undergone firstline LSG (n = 1108). Indication for surgery The indication for bariatric surgery had been validated in a multidisciplinary staff meeting in accordance with French national guidelines [10]. All patients attended a surgical consultation, a nutritional and dietetic consultation and completed pulmonary, endocrine and psychological assessments. Screening for hiatus hernia and Helicobacter pylori infections was performed gastroscopically. Pulmonary function tests were used to screen for obstructive sleep apnea syndrome. Surgical technique The SG technique was described by Dhahri et al. [11]. SG was performed using 4 trocars (COVIDEN France SAS, Elancourt, France). The patient was placed in the French position. The surgeon was in place between the patient’s legs, and the first assistant was on the patient’s left. An open laparoscopy technique was systematically used for supramesocolic surgery in all obese patients, as previously described [12], with 2 sutures on the anterior fascia and 2 sutures on the posterior fascia of rectus abdominis using absorbable suture (such as Vicryl 0, Ethicon France SAS, Issy Les Moulineaux, France). This technique allows easier and more rapid closure of the abdominal wall at the end of the surgical procedure. A Veress needle was never used to establish pneumoperitoneum. Open laparoscopy comprises insertion of a 15-mm trocar. Two 12-mm trocars (1 epigastric and 1 left subcostal margin) and one 5-mm trocar (right subcostal margin) were then used (Fig. 1). For open laparoscopy, a bladeless trocar (such as a 15-mm Versaport Plus) was used. For left subcostal margin and epigastric trocars,
Fig. 1. Position of the trocar site during laparoscopic sleeve gastrectomy.
bladed trocars (such as a 12-mm long Versaport Plus V² with fixation) were used. For the right subcostal margin, bladed trocars also were used (such as the 5-mm long Versaport Plus V2, COVIDIEN France SAS, Elancourt, France). Trocar sites measuring 12 mm and 5 mm were not closed at the end of SG. At the end of the surgical procedure, a suture was placed laparoscopically on one edge of the resected stomach. This allowed us to expose one edge of the stomach for easy extraction of a specimen and without opening the fascia further.
Trocar site hernia evaluation TSHs were evaluated with an abdominal CT scan and defined as a gap in the abdominal wall (with or without a bulge) in the vicinity of a postoperative scar. All abdominal CT scans were evaluated on a double-blind basis by 2 radiologists with experience of the postoperative assessment of obesity surgery. Abdominal CT scan was performed for gastric volumetry in the context of a local protocol (study declared to ClinicalTrials.gov, Identifier: NCT01539967) [13], because of insufficient weight loss or weight regain, and for other causes not directly related to the SG procedure.
Inclusion criteria Patients included in the study had to meet all of the following inclusion criteria: patient undergoing primary SG and abdominal CT scan performed at least 3 months after SG. Patients requiring conversion to laparotomy or laparotomy for postoperative complications, undergoing surgical procedures other than primary SG, and having abdominal CT scan performed for assessment of complications after SG (gastric leaks, bleeding, etc.) due to the risk of increased abdominal pressure that may increase the risk of TSH were excluded from the study.
Trocar Site Hernia After Laparoscopic Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 791–797
Endpoints and collected data The primary endpoint of this study was the TSH rate after SG. The secondary endpoints were the site of TSH, the TSH rate with the authors’ open laparoscopy technique, the indication for abdominal CT scan, and risk factors for TSH. The following study parameters were collected: (1) preoperative data (age, gender, body mass index [BMI], type 2 diabetes, dyslipidemia, hypertension, obstructive sleep apnea syndrome, metabolic syndrome [NCEPATP3]); (2) abdominal CT scan data (indication for abdominal CT scan, interval between abdominal CT scan and SG, time interval to performance of an abdominal CT scan [3–12 months after SG, 13–24 months after SG, and 424 months after SG]); and (3) trocar site hernia data (overall and 1-year TSH rate, site of TSH, TSH rate with the authors’ open laparoscopy technique, proportion of patients with painful TSH symptoms, strangulated TSH rate, and the impact of weight regain on the TSH rate). Statistical analysis Between-group comparisons of qualitative variables were performed with Fisher’s exact test. Between-group comparisons of quantitative variables (including the primary endpoint) were performed with a Student t test. Unless otherwise stated, the results were expressed as the mean ⫾ standard deviation and/or median (range) (for quantitative variables) or number and percentage (for qualitative variables). The limit for statistical significance was P r .05. All statistical analyses were performed with SAS software version 9.2 (SAS Institute, Cary, NC) Risk factors for postoperative trocar site hernia were also investigated, such as gender (male versus female), age, preoperative BMI and BMI Z 50 kg/m2, type II diabetes, hypertension, dyslipidemia, sleep apnea syndrome, metabolic syndrome, operating time, trocar site, and wound infection. Variables with a P value r.2 on univariate analysis were included in a multivariate model. Risk factors were expressed as a relative risk with a 95% confidence interval.
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patients (34.2%) had a BMI Z50 kg/m2. Co-morbidities were type 2 diabetes (43.4%, n ¼ 99), hypertension (38.1%, n ¼ 87), dyslipidemia (31.1%, n ¼ 71), obstructive sleep apnea syndrome (37.3%, n ¼ 85), and metabolic syndrome (28%, n ¼ 64). Operative data The mean operating time was 90 ⫾ 28 minutes (45–180 min). Open laparoscopy was performed successfully in all cases (100%) and was associated with no morbidity (no injury to intraperitoneal organs). Two patients developed early postoperative strangulated TSH (one on postoperative day 1 and one on postoperative day 2) diagnosed in a context of vomiting by means of abdominal CT scan. The TSH was situated at the open laparoscopy site (1 case without bowel resection) (Fig. 2) and on the epigastric site (1 case with bowel resection). During the redo surgical procedure for strangulated TSH at the open laparoscopy port site, the abdominal wall wound was completely dehiscent. Trocar site wound infections were present in 5 cases (2.2%). The infections were located on the left subcostal margin in 2 cases, in the epigastric area in 1 case, on the right subcostal margin in 1 case, and at the open laparoscopy site on 1 case. All the trocar site infections were associated with poor scar closure. They did not require incision and drainage under general anesthesia; local treatment was sufficient, and hospitalization was not required. Clinical analysis During follow-up, 5 patients reported symptoms of abdominal pain related to the hernia site and underwent hernia repair. Four of these patients had a hernia measuring 45 cm in diameter, and 1 patient had a hernia measuring o5 cm in diameter. All other patients with TSH were asymptomatic and presented a TSH with a
Results Population During the study period, 1108 patients underwent firstline SG. Ten patients in this population required conversion to laparotomy and were excluded from this analysis. The authors’ open laparoscopy technique was performed in all of the remaining 1098 patients, and abdominal CT scan was performed in 228 of these patients for indications unrelated to SG complications (20.7%). The study population comprised 228 patients (47 men [20.6%]) with a mean age of 45.1 ⫾ 11 [18–68]) and a mean BMI of 47.6 ⫾ 7.3 kg/m2 [33–75.4]). Seventy-eight
Fig. 2. Abdominal computed tomography scan performed on postoperative day 1 showing strangulated trocar site hernia (white arrow) on the open laparoscopy port site.
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diameter of o3 cm (Figs. 2 and 3). The incidence of symptomatic TSH was 11.6% (5 of 43 patients). No case of strangulated TSH requiring emergency incisional hernia repair was observed during follow-up of all patients undergoing SG (n = 1098). CT scan data and trocar site analysis The median time interval between SG and CT scan was 27 months (range: 3–92 mo). Abdominal CT scans were performed for gastric volumetry (81.5%, n = 186) and for other reasons in 42 cases (cancer disease, gallbladder diseases, renal colic, etc.). Five abdominal CT scans were performed for recurrent abdominal pain. A TSH was detected in 4 of these 5 patients, and CT scan was performed for assessment of the TSH. The last patient had a TSH that was not perceptible clinically and reported abdominal pain related to TSH. CT scan revealed 44 TSHs in 43 patients (18.8%); one patient had 2 TSHs. The sites of the TSHs were epigastric (16.6%, n = 38), open laparoscopy (1.7%, n = 4), and right subcostal margin (0.8%, n = 2), with no TSH in the left subcostal margin. The TSH rate in patients with 41 year of follow-up was 19.7% (38 TSHs in 192 patients). The TSH rate was 13.8% (5 of 36 patients) for a time interval between SG and the abdominal CT scan of 3 to 12 months, 19% (12 of 63 patients) for a time interval of 13 to 24 months, and 20.1% (26 of 129 patients) for a time interval 424 months. Risk factors for trocar site hernia Univariate analysis of this study population of 228 SG did not identify any risk factors for trocar site hernia (Table 1).
Fig. 3. Abdominal computed tomography scan of symptomatic trocar site hernia at the epigastric port site (black arrow) measuring o5 cm in diameter.
Table 1 Risk factors and site of trocar site hernia after sleeve gastrectomy Risk factor
TSH group n ¼ 43
Control group n ¼ 185
P
Male gender (%) Age (years) Preoperative BMI (kg/m²) BMI Z50 kg/m2 (%) Type 2 diabetes (%) Hypertension (%) Dyslipidemia (%) OSA (%) Metabolic syndrome (%) Operative time (min) Weight regain (%) Site of trocar site hernia Open laparoscopy Epigastric Right subcostal margin Left subcostal margin
8 (18.6) 44.7 48.2 16 (37.2) 17 (39.5) 14 (29.1) 13 (27.0) 13 (27.0) 13 (27.0) 86.5 7 (16.2)
39 (21.0) 45.2 47.5 62 (33.5) 82 (44.3) 73 (39.4) 58 (31.3) 72 ( 38.9) 51 (27.5) 90.9 27 (15.1)
0.72 0.79 0.62 0.75 0.66 0.37 0.89 0.32 0.73 0.33 0.65
4 38 2 0
– – – –
– – – –
BMI ¼ body mass index; OSA ¼ obstructive sleep apnea.
Discussion TSH is defined as an incisional hernia occurring after laparoscopic procedures at the trocar incision site [14]. Some risk factors for TSH have been identified, such as design and size of the trocars (12-mm diameter) [15], trocar site [16], long operating time [15], female gender, and advanced age [4,17]. Although some studies have compared laparoscopy entry techniques [18], no clear guidelines in favor of a particular laparoscopy technique (direct approach, Veress needle, or open laparoscopy) are available. In the authors’ institution, open laparoscopy is performed systematically for all types of surgical procedures. The main problem with open laparoscopy in obese patients concerns closure of the fascia at the end of the surgical procedure. For this reason, a specific technique is used in obese patients by inserting the sutures at the beginning of the procedure before any tissue damage [12]. A recent study [7] reported a lower TSH rate after bariatric surgery (0.5%) than after colorectal surgery (1.5%). These results may appear somewhat surprising, because the abdominal wall of obese patients is more fragile and subject to higher abdominal pressures due to obesity. Morbid obesity has been found to be a risk factor in the development of incisional hernia after laparotomy due to intraabdominal pressure [19]. Thus, the incisional hernia rates after surgery (including laparotomy for bariatric surgery) range from 20% to 39% [20]. Furthermore, the study by Sauerland et al., of various types of hernia surgery, found that the recurrence rate was 2 to 3 times higher in obese patients (BMI 4 30) than in nonobese patients [21]. Erdas et al. [22] showed that obesity was the major risk factor for TSH after cholecystectomy with an odds ratio of 29. Evaluation of TSH in this series was performed clinically and then by ultrasound when TSH was suspected.
Trocar Site Hernia After Laparoscopic Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 791–797
Most series evaluating the incidence of TSH after bariatric surgery have been based on clinical evaluation [8,9]. The TSH rate in these series ranges from 0% to .7%. The main bias of these studies is that clinical evaluation of the abdominal wall in an obese patient, even after significant weight loss, is very difficult, and only 2.2% of the present study population had clinically evident TSH (similar to the rate reported in the above series). In addition, for 2 patients with postoperative trocar site incisional hernia, the only symptoms were vomiting with no abdominal pain or wound infection. These hernias were not clinically perceptible, and the diagnosis was established by abdominal CT scan. In the present series, the sensitivity and specificity of a CT scan for evaluating TSH were both 100%, and the 2 radiologists always agreed on the CT-based evaluation of TSH. In the present series, TSH was clinically perceptible only in the case of large diameter TSH, and all but one of the other TSHs were incidental findings. The authors recently proposed an open laparoscopy technique for obese patients to systematically close the posterior and anterior planes of the abdominal wall at the incision site at the end of the surgical procedure. This study evaluated the results of this technique and found only 4 cases of incisional hernia visible on abdominal CT scan (1.7%) and 1 case of incisional hernia related to wound dehiscence. These results confirm that the authors’ technique is feasible and provides good results on long-term evaluation. This technique has been extended not only to patients undergoing bariatric surgery but to all obese patients undergoing laparoscopic surgery. Most TSHs were situated at the epigastric port site, as also observed in the study by Scozzari et al. [23], in which the TSH rate was even higher (26.2% in the laparoscopic group and 37.9% in the robotic group), partly explained by the fact that the linea alba is an area of weakness of the abdominal wall. Pilone et al. [24] recently published their experience of TSH in 624 patients after bariatric surgery without fascial closure. In this series, closure of the trocar site port was not performed because it is simpler, less time-consuming, and due to the risk of injury to intraperitoneal organs. Their series comprised 10 cases of TSH (1.5%) with a mean follow-up of 54 months. The authors concluded that leaving the fascia unclosed after laparoscopic bariatric surgery provided good results. The major bias of their study was that evaluation was also performed clinically. A number of cases of TSH may not be detected clinically, and when TSH occurs, it does not resolve spontaneously. These asymptomatic hernias at 5 years of follow-up may become symptomatic at 10 or 20 years. The time-consuming argument is no longer valid, as Del Junco et al. [25] showed that fascial closure using appropriate equipment was feasible and not time-consuming with a mean fascial closure time, according the 2 types of material used, of 98 seconds and 133 seconds, respectively. One other possible source of bias was the long time interval between surgery and evaluation of TSH (ranging
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from 3 to 92 months); this factor may have increased the recorded incidence of TSH in patients with 44 years of follow-up. Nevertheless, the present study is the first to have such a long follow-up period; the main take-home message is that the incidence of TSH is underestimated and that surgeons should adapt their technique in light of these results. The authors now systematically close the epigastric trocar site port at the end of SG procedures, to reduce TSH rate. Conclusion The TSH rate after bariatric surgery is underestimated. The TSH rate in the present series was 18.8%. The open laparoscopy technique is a reliable technique with a low hernia rate compared with the TSH rate at the epigastric trocar site. In the light of these results, the authors systematically close the epigastric trocar site at the end of SG. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013;257:231–7. [2] Prevot F, Verhaeghe P, Pequignot A, et al. Two lessons from a 5-year follow-up study of laparoscopic sleeve gastrectomy: persistent, relevant weight loss and a short surgical learning curve. Surgery 2014;155:292–9. [3] Eid GM, Brethauer S, Mattar SG, Titchner RL, Gourash W, Schauer PR. Laparoscopic sleeve gastrectomy for super obese patients: fortyeight percent excess weight loss after 6 to 8 years with 93% followup. Ann Surg 2012;256:262–5. [4] Uslu HY, Erkek AB, Cakmak A, et al. Trocar site hernia after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2007;17:600–3. [5] Sanz-Lopez R, Martinez-Ramos C, Nunez-Pena JR, Ruiz de Gopegui M, Pastor-Sirera L, Tamames-Escobar S. Incisional hernias after laparoscopic vs open cholecystectomy. Surg Endosc 1999;13:922–4. [6] Comajuncosas J, Hermoso J, Gris P, et al. Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study. Am J Surg 2014;207:1–6. [7] Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surgeon 2011;9:218–24. [8] Lee DY, Rehmani SS, Guend H, et al. The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy. Surg Endosc 2013;27:1287–91. [9] Sucher R, Resch T, Mohr E, et al. Single-incision laparoscopic sleeve gastrectomy versus multiport laparoscopic sleeve gastrectomy: analysis of 80 cases in a single center. J Laparoendosc Adv Surg Tech A 2014;24:83–8. [10] Gastrectomie Longitudinale [sleeve gastrectomy] pour obésité. Haute autorité de la santé. Recommandations 2008. www.has-sante.fr/por tail/upload/docs/application/pdf/2009-09fiche_technique_gastrecto mie_080909.pdf.
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[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
Original article
Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique Lionel Rebibo, M.D.a,c, Abdennaceur Dhahri, M.D.a,c, Cyril Chivot, M.D.b,c, Cosse Cyril, Ph.Da,c, Thierry Yzet, M.D., Ph.Db,c, Jean-Marc Regimbeau, M.D., Ph.D.a,c,* a
Department of Digestive Surgery, Amiens University Hospital, Amiens, France b Department of Radiology, Amiens University Hospital, Amiens, France c Jules Verne University of Picardie, Amiens, France Received August 31, 2014; accepted November 30, 2014
Abstract
Background: Obesity is recognized as a risk factor for trocar site hernia (TSH) after laparoscopic surgery. Some recent studies have reported a TSH rate after bariatric surgery ranging from 0% to 1.6% using clinical evaluation and may underestimate the TSH rate. The objective of this study was to evaluate the TSH rate after sleeve gastrectomy (SG) by abdominal computed tomography (CT) scan. Methods: A retrospective review of all patients who underwent first-line SG and abdominal CT scan between March 2004 and February 2014 was performed. The primary endpoint was the incidence of TSH. Secondary endpoints were the site of TSH, the TSH rate with open laparoscopy using the authors’ technique, and risk factors for TSH after SG. Results: During the period study, 1108 patients underwent first-line SG, including 10 cases of conversion to laparotomy (excluded from the present analysis). Of the remaining patients, 228 had abdominal CT scan (20.7%), with a mean age of 45.1 years (18–68 yr) and a mean BMI of 47.6 kg/ m2 (33–75.4 kg/m2). The median time interval between SG and CT scan was 27 months (3–92 mo). CT scan revealed 44 TSH in 43 patients (18.8%). The site of the TSH was epigastric (16.6%), open laparoscopy (1.7%), right subcostal margin (0.8%), with no TSH in the left subcostal margin. In patients with 41 year of follow-up, the TSH rate was 19.7%. Conclusion: The TSH rate after bariatric surgery is underestimated. The authors’ open laparoscopy technique is a reliable technique with a low TSH rate. In the light of these results, the epigastric trocar site is systematically closed at the end of SG. (Surg Obes Relat Dis 2015;11:791–797.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Sleeve gastrectomy; Abdominal CT scan; Trocar site hernia; Open laparoscopy
The use of laparoscopy has promoted the growth of bariatric surgery, with increasing numbers of surgical procedures performed all over the world. Sleeve gastrectomy (SG) is currently the surgical procedure most commonly performed in France because of its relative * Correspondence: Jean-Marc Regimbeau, M.D., Ph.D., Department of Digestive Surgery, Hôpital Nord, CHU d'Amiens, Place Victor Pauchet, F80054 Amiens cedex 01, France. E-mail: [email protected]
simplicity, its low complication rate [1], and good results in terms of weight loss with 45 years of follow-up [2,3]. However, trocar site hernia (TSH) is a long-term complication that is not specific to SG. The risk factors for incisional hernia include surgical wound infections, age, trocar site (close to the linea alba), and the size of the trocars used (410 mm diameter) [4,5]. Obesity is also a recognized risk factor for TSH after laparoscopic surgery [6]. However, some recent studies have reported lower TSH rates after bariatric surgery than
http://dx.doi.org/10.1016/j.soard.2014.11.028 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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after colorectal surgery [7]. Other series have also reported TSH rates after bariatric surgery ranging from 0% to 1.6% [8,9]. The problem with such series is that evaluation of TSH rate is purely clinical, and clinical evaluation of incisional hernia (particularly TSH) can sometimes be difficult in obese patients, despite weight loss after surgery. The objective of this study was to evaluate the TSH rate after laparoscopic SG by abdominal computed tomography (CT) scan and to evaluate the incisional hernia rate of the authors’ open laparoscopy technique for obese patients. Methods Population From March 2004 to February 2014, all patients undergoing abdominal CT scan at least 3 months after SG procedures were included in the study (n = 228), which therefore consisted of a retrospective review of a prospective database in a group of patients having undergone firstline LSG (n = 1108). Indication for surgery The indication for bariatric surgery had been validated in a multidisciplinary staff meeting in accordance with French national guidelines [10]. All patients attended a surgical consultation, a nutritional and dietetic consultation and completed pulmonary, endocrine and psychological assessments. Screening for hiatus hernia and Helicobacter pylori infections was performed gastroscopically. Pulmonary function tests were used to screen for obstructive sleep apnea syndrome. Surgical technique The SG technique was described by Dhahri et al. [11]. SG was performed using 4 trocars (COVIDEN France SAS, Elancourt, France). The patient was placed in the French position. The surgeon was in place between the patient’s legs, and the first assistant was on the patient’s left. An open laparoscopy technique was systematically used for supramesocolic surgery in all obese patients, as previously described [12], with 2 sutures on the anterior fascia and 2 sutures on the posterior fascia of rectus abdominis using absorbable suture (such as Vicryl 0, Ethicon France SAS, Issy Les Moulineaux, France). This technique allows easier and more rapid closure of the abdominal wall at the end of the surgical procedure. A Veress needle was never used to establish pneumoperitoneum. Open laparoscopy comprises insertion of a 15-mm trocar. Two 12-mm trocars (1 epigastric and 1 left subcostal margin) and one 5-mm trocar (right subcostal margin) were then used (Fig. 1). For open laparoscopy, a bladeless trocar (such as a 15-mm Versaport Plus) was used. For left subcostal margin and epigastric trocars,
Fig. 1. Position of the trocar site during laparoscopic sleeve gastrectomy.
bladed trocars (such as a 12-mm long Versaport Plus V² with fixation) were used. For the right subcostal margin, bladed trocars also were used (such as the 5-mm long Versaport Plus V2, COVIDIEN France SAS, Elancourt, France). Trocar sites measuring 12 mm and 5 mm were not closed at the end of SG. At the end of the surgical procedure, a suture was placed laparoscopically on one edge of the resected stomach. This allowed us to expose one edge of the stomach for easy extraction of a specimen and without opening the fascia further.
Trocar site hernia evaluation TSHs were evaluated with an abdominal CT scan and defined as a gap in the abdominal wall (with or without a bulge) in the vicinity of a postoperative scar. All abdominal CT scans were evaluated on a double-blind basis by 2 radiologists with experience of the postoperative assessment of obesity surgery. Abdominal CT scan was performed for gastric volumetry in the context of a local protocol (study declared to ClinicalTrials.gov, Identifier: NCT01539967) [13], because of insufficient weight loss or weight regain, and for other causes not directly related to the SG procedure.
Inclusion criteria Patients included in the study had to meet all of the following inclusion criteria: patient undergoing primary SG and abdominal CT scan performed at least 3 months after SG. Patients requiring conversion to laparotomy or laparotomy for postoperative complications, undergoing surgical procedures other than primary SG, and having abdominal CT scan performed for assessment of complications after SG (gastric leaks, bleeding, etc.) due to the risk of increased abdominal pressure that may increase the risk of TSH were excluded from the study.
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Endpoints and collected data The primary endpoint of this study was the TSH rate after SG. The secondary endpoints were the site of TSH, the TSH rate with the authors’ open laparoscopy technique, the indication for abdominal CT scan, and risk factors for TSH. The following study parameters were collected: (1) preoperative data (age, gender, body mass index [BMI], type 2 diabetes, dyslipidemia, hypertension, obstructive sleep apnea syndrome, metabolic syndrome [NCEPATP3]); (2) abdominal CT scan data (indication for abdominal CT scan, interval between abdominal CT scan and SG, time interval to performance of an abdominal CT scan [3–12 months after SG, 13–24 months after SG, and 424 months after SG]); and (3) trocar site hernia data (overall and 1-year TSH rate, site of TSH, TSH rate with the authors’ open laparoscopy technique, proportion of patients with painful TSH symptoms, strangulated TSH rate, and the impact of weight regain on the TSH rate). Statistical analysis Between-group comparisons of qualitative variables were performed with Fisher’s exact test. Between-group comparisons of quantitative variables (including the primary endpoint) were performed with a Student t test. Unless otherwise stated, the results were expressed as the mean ⫾ standard deviation and/or median (range) (for quantitative variables) or number and percentage (for qualitative variables). The limit for statistical significance was P r .05. All statistical analyses were performed with SAS software version 9.2 (SAS Institute, Cary, NC) Risk factors for postoperative trocar site hernia were also investigated, such as gender (male versus female), age, preoperative BMI and BMI Z 50 kg/m2, type II diabetes, hypertension, dyslipidemia, sleep apnea syndrome, metabolic syndrome, operating time, trocar site, and wound infection. Variables with a P value r.2 on univariate analysis were included in a multivariate model. Risk factors were expressed as a relative risk with a 95% confidence interval.
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patients (34.2%) had a BMI Z50 kg/m2. Co-morbidities were type 2 diabetes (43.4%, n ¼ 99), hypertension (38.1%, n ¼ 87), dyslipidemia (31.1%, n ¼ 71), obstructive sleep apnea syndrome (37.3%, n ¼ 85), and metabolic syndrome (28%, n ¼ 64). Operative data The mean operating time was 90 ⫾ 28 minutes (45–180 min). Open laparoscopy was performed successfully in all cases (100%) and was associated with no morbidity (no injury to intraperitoneal organs). Two patients developed early postoperative strangulated TSH (one on postoperative day 1 and one on postoperative day 2) diagnosed in a context of vomiting by means of abdominal CT scan. The TSH was situated at the open laparoscopy site (1 case without bowel resection) (Fig. 2) and on the epigastric site (1 case with bowel resection). During the redo surgical procedure for strangulated TSH at the open laparoscopy port site, the abdominal wall wound was completely dehiscent. Trocar site wound infections were present in 5 cases (2.2%). The infections were located on the left subcostal margin in 2 cases, in the epigastric area in 1 case, on the right subcostal margin in 1 case, and at the open laparoscopy site on 1 case. All the trocar site infections were associated with poor scar closure. They did not require incision and drainage under general anesthesia; local treatment was sufficient, and hospitalization was not required. Clinical analysis During follow-up, 5 patients reported symptoms of abdominal pain related to the hernia site and underwent hernia repair. Four of these patients had a hernia measuring 45 cm in diameter, and 1 patient had a hernia measuring o5 cm in diameter. All other patients with TSH were asymptomatic and presented a TSH with a
Results Population During the study period, 1108 patients underwent firstline SG. Ten patients in this population required conversion to laparotomy and were excluded from this analysis. The authors’ open laparoscopy technique was performed in all of the remaining 1098 patients, and abdominal CT scan was performed in 228 of these patients for indications unrelated to SG complications (20.7%). The study population comprised 228 patients (47 men [20.6%]) with a mean age of 45.1 ⫾ 11 [18–68]) and a mean BMI of 47.6 ⫾ 7.3 kg/m2 [33–75.4]). Seventy-eight
Fig. 2. Abdominal computed tomography scan performed on postoperative day 1 showing strangulated trocar site hernia (white arrow) on the open laparoscopy port site.
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diameter of o3 cm (Figs. 2 and 3). The incidence of symptomatic TSH was 11.6% (5 of 43 patients). No case of strangulated TSH requiring emergency incisional hernia repair was observed during follow-up of all patients undergoing SG (n = 1098). CT scan data and trocar site analysis The median time interval between SG and CT scan was 27 months (range: 3–92 mo). Abdominal CT scans were performed for gastric volumetry (81.5%, n = 186) and for other reasons in 42 cases (cancer disease, gallbladder diseases, renal colic, etc.). Five abdominal CT scans were performed for recurrent abdominal pain. A TSH was detected in 4 of these 5 patients, and CT scan was performed for assessment of the TSH. The last patient had a TSH that was not perceptible clinically and reported abdominal pain related to TSH. CT scan revealed 44 TSHs in 43 patients (18.8%); one patient had 2 TSHs. The sites of the TSHs were epigastric (16.6%, n = 38), open laparoscopy (1.7%, n = 4), and right subcostal margin (0.8%, n = 2), with no TSH in the left subcostal margin. The TSH rate in patients with 41 year of follow-up was 19.7% (38 TSHs in 192 patients). The TSH rate was 13.8% (5 of 36 patients) for a time interval between SG and the abdominal CT scan of 3 to 12 months, 19% (12 of 63 patients) for a time interval of 13 to 24 months, and 20.1% (26 of 129 patients) for a time interval 424 months. Risk factors for trocar site hernia Univariate analysis of this study population of 228 SG did not identify any risk factors for trocar site hernia (Table 1).
Fig. 3. Abdominal computed tomography scan of symptomatic trocar site hernia at the epigastric port site (black arrow) measuring o5 cm in diameter.
Table 1 Risk factors and site of trocar site hernia after sleeve gastrectomy Risk factor
TSH group n ¼ 43
Control group n ¼ 185
P
Male gender (%) Age (years) Preoperative BMI (kg/m²) BMI Z50 kg/m2 (%) Type 2 diabetes (%) Hypertension (%) Dyslipidemia (%) OSA (%) Metabolic syndrome (%) Operative time (min) Weight regain (%) Site of trocar site hernia Open laparoscopy Epigastric Right subcostal margin Left subcostal margin
8 (18.6) 44.7 48.2 16 (37.2) 17 (39.5) 14 (29.1) 13 (27.0) 13 (27.0) 13 (27.0) 86.5 7 (16.2)
39 (21.0) 45.2 47.5 62 (33.5) 82 (44.3) 73 (39.4) 58 (31.3) 72 ( 38.9) 51 (27.5) 90.9 27 (15.1)
0.72 0.79 0.62 0.75 0.66 0.37 0.89 0.32 0.73 0.33 0.65
4 38 2 0
– – – –
– – – –
BMI ¼ body mass index; OSA ¼ obstructive sleep apnea.
Discussion TSH is defined as an incisional hernia occurring after laparoscopic procedures at the trocar incision site [14]. Some risk factors for TSH have been identified, such as design and size of the trocars (12-mm diameter) [15], trocar site [16], long operating time [15], female gender, and advanced age [4,17]. Although some studies have compared laparoscopy entry techniques [18], no clear guidelines in favor of a particular laparoscopy technique (direct approach, Veress needle, or open laparoscopy) are available. In the authors’ institution, open laparoscopy is performed systematically for all types of surgical procedures. The main problem with open laparoscopy in obese patients concerns closure of the fascia at the end of the surgical procedure. For this reason, a specific technique is used in obese patients by inserting the sutures at the beginning of the procedure before any tissue damage [12]. A recent study [7] reported a lower TSH rate after bariatric surgery (0.5%) than after colorectal surgery (1.5%). These results may appear somewhat surprising, because the abdominal wall of obese patients is more fragile and subject to higher abdominal pressures due to obesity. Morbid obesity has been found to be a risk factor in the development of incisional hernia after laparotomy due to intraabdominal pressure [19]. Thus, the incisional hernia rates after surgery (including laparotomy for bariatric surgery) range from 20% to 39% [20]. Furthermore, the study by Sauerland et al., of various types of hernia surgery, found that the recurrence rate was 2 to 3 times higher in obese patients (BMI 4 30) than in nonobese patients [21]. Erdas et al. [22] showed that obesity was the major risk factor for TSH after cholecystectomy with an odds ratio of 29. Evaluation of TSH in this series was performed clinically and then by ultrasound when TSH was suspected.
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Most series evaluating the incidence of TSH after bariatric surgery have been based on clinical evaluation [8,9]. The TSH rate in these series ranges from 0% to .7%. The main bias of these studies is that clinical evaluation of the abdominal wall in an obese patient, even after significant weight loss, is very difficult, and only 2.2% of the present study population had clinically evident TSH (similar to the rate reported in the above series). In addition, for 2 patients with postoperative trocar site incisional hernia, the only symptoms were vomiting with no abdominal pain or wound infection. These hernias were not clinically perceptible, and the diagnosis was established by abdominal CT scan. In the present series, the sensitivity and specificity of a CT scan for evaluating TSH were both 100%, and the 2 radiologists always agreed on the CT-based evaluation of TSH. In the present series, TSH was clinically perceptible only in the case of large diameter TSH, and all but one of the other TSHs were incidental findings. The authors recently proposed an open laparoscopy technique for obese patients to systematically close the posterior and anterior planes of the abdominal wall at the incision site at the end of the surgical procedure. This study evaluated the results of this technique and found only 4 cases of incisional hernia visible on abdominal CT scan (1.7%) and 1 case of incisional hernia related to wound dehiscence. These results confirm that the authors’ technique is feasible and provides good results on long-term evaluation. This technique has been extended not only to patients undergoing bariatric surgery but to all obese patients undergoing laparoscopic surgery. Most TSHs were situated at the epigastric port site, as also observed in the study by Scozzari et al. [23], in which the TSH rate was even higher (26.2% in the laparoscopic group and 37.9% in the robotic group), partly explained by the fact that the linea alba is an area of weakness of the abdominal wall. Pilone et al. [24] recently published their experience of TSH in 624 patients after bariatric surgery without fascial closure. In this series, closure of the trocar site port was not performed because it is simpler, less time-consuming, and due to the risk of injury to intraperitoneal organs. Their series comprised 10 cases of TSH (1.5%) with a mean follow-up of 54 months. The authors concluded that leaving the fascia unclosed after laparoscopic bariatric surgery provided good results. The major bias of their study was that evaluation was also performed clinically. A number of cases of TSH may not be detected clinically, and when TSH occurs, it does not resolve spontaneously. These asymptomatic hernias at 5 years of follow-up may become symptomatic at 10 or 20 years. The time-consuming argument is no longer valid, as Del Junco et al. [25] showed that fascial closure using appropriate equipment was feasible and not time-consuming with a mean fascial closure time, according the 2 types of material used, of 98 seconds and 133 seconds, respectively. One other possible source of bias was the long time interval between surgery and evaluation of TSH (ranging
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from 3 to 92 months); this factor may have increased the recorded incidence of TSH in patients with 44 years of follow-up. Nevertheless, the present study is the first to have such a long follow-up period; the main take-home message is that the incidence of TSH is underestimated and that surgeons should adapt their technique in light of these results. The authors now systematically close the epigastric trocar site port at the end of SG procedures, to reduce TSH rate. Conclusion The TSH rate after bariatric surgery is underestimated. The TSH rate in the present series was 18.8%. The open laparoscopy technique is a reliable technique with a low hernia rate compared with the TSH rate at the epigastric trocar site. In the light of these results, the authors systematically close the epigastric trocar site at the end of SG. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013;257:231–7. [2] Prevot F, Verhaeghe P, Pequignot A, et al. Two lessons from a 5-year follow-up study of laparoscopic sleeve gastrectomy: persistent, relevant weight loss and a short surgical learning curve. Surgery 2014;155:292–9. [3] Eid GM, Brethauer S, Mattar SG, Titchner RL, Gourash W, Schauer PR. Laparoscopic sleeve gastrectomy for super obese patients: fortyeight percent excess weight loss after 6 to 8 years with 93% followup. Ann Surg 2012;256:262–5. [4] Uslu HY, Erkek AB, Cakmak A, et al. Trocar site hernia after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2007;17:600–3. [5] Sanz-Lopez R, Martinez-Ramos C, Nunez-Pena JR, Ruiz de Gopegui M, Pastor-Sirera L, Tamames-Escobar S. Incisional hernias after laparoscopic vs open cholecystectomy. Surg Endosc 1999;13:922–4. [6] Comajuncosas J, Hermoso J, Gris P, et al. Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study. Am J Surg 2014;207:1–6. [7] Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surgeon 2011;9:218–24. [8] Lee DY, Rehmani SS, Guend H, et al. The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy. Surg Endosc 2013;27:1287–91. [9] Sucher R, Resch T, Mohr E, et al. Single-incision laparoscopic sleeve gastrectomy versus multiport laparoscopic sleeve gastrectomy: analysis of 80 cases in a single center. J Laparoendosc Adv Surg Tech A 2014;24:83–8. [10] Gastrectomie Longitudinale [sleeve gastrectomy] pour obésité. Haute autorité de la santé. Recommandations 2008. www.has-sante.fr/por tail/upload/docs/application/pdf/2009-09fiche_technique_gastrecto mie_080909.pdf.
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[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
