Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review

Background In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min. Case presentation A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence. Conclusions The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Laparoscopic-Guided Ropivacaine Trocar-Site Infiltration Can Improve Post-Operative Pain Control after Laparoscopic Adrenalectomy

Background There is no consensus on pain control in patients undergoing laparoscopy; nowadays, conventional therapy may be improved by transversus abdominis plane block. The aim of this evaluation is to investigate the role of laparoscopic-assisted trocar-site ropivacaine infiltration during adrenalectomy in pain control Methods This is a retrospective evaluation of a prospectively maintained database including patients undergoing adrenalectomy. Patients were divided into 2 groups: Group A patients received laparoscopic-assisted trocar-site infiltration of 7.5 mg/mL ropivacaine and Group B patients did not receive any infiltration. All patients received a 24-hour infusion of 20 mg morphine; pain was checked at 6, 24, and 48 hours after surgery by Visual Analogue Scale (VAS) score. A rescue analgesia by was given if VAS score was > 4 or on patient request. Results No differences in operative time, complications, and post-operative stay and no complications related to trocar-site infiltration were found. 6-hour and 48-hour VAS scores were not found to be significantly different between groups, even if a slight decrease in VAS score in Group A was reported. Group A showed significant reduction in VAS score at 24 hours (2.44 +/− .41 vs 3.01 +/− .78, P < .005) and in the number of patients requiring further analgesic drugs administration (40.6% vs 57.8%, P < .005) Conclusions Laparoscopic-guided trocar-site ropivacaine infiltration can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic adrenalectomy. The retrospective nature of the study and the lack of a consistent series of patients require further evaluations.

P060 TROCAR SITE HERNIA AFTER GASTRIC SLEEVE

Aim Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position upon a ring was found to be a reliable method for the detection of TSH in obese. Our aim was to examine the incidence of TSH after gastric sleeve. Material and Methods 79 patients subjected to laparoscopic gastric sleeve in 2011-2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey. Results The incidence of trocar site hernia was 17 out of 79 (21,5 %), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no clear correlation between symptomatic TSH and TSH on CT. Conclusions The incidence of TSH is high in this group of patients. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of trocar site hernia can be serious, the proportion of symptomatic TSH is unknown.

Umbilical trocar port site keloid management using a transposition flap after laparoscopic surgery

Background Keloids can occur anywhere in the human body. They are difficult to remove and can cause distress in patients. Although many options are available to treat keloids, no single method is considered the optimal treatment of choice. The authors encountered cases where an umbilical keloid developed at the trocar site after laparoscopic surgery and managed the keloid using a transposition flap.Methods A total of 10 umbilical keloid patients treated from 2013 to 2020 were included in this study. All patients developed a keloid due to the placement of a laparoscopic trocar incision port, and their major complaints varied from an asymptomatic nodule to pruritus or pain. All excisions were performed under local anesthesia, and transposition flaps were planned afterward. The surrounding tissue was rearranged so that the shape of the umbilicus was deformed to the minimum extent possible. The keloid scars were examined both preoperatively and 6 months postoperatively using the Patient and Observer Scar Assessment Scale (POSAS).Results All surgical wounds healed well without complications. The average time interval from laparoscopic surgery to keloid scar revision was 4.3 years. The mean postoperative follow-up period was 10.9 months, and no patient underwent reoperation. Four patients were treated with triamcinolone after surgery due to mild hypertrophy or pruritus. The POSAS observer scale showed significantly decreasing scores over time in all patients (P=0.002).Conclusions Cosmetically unfavorable keloids that form in the umbilicus following laparoscopic surgery can be improved with a simple procedure using excision and transposition flaps.

Trocar site hernia after gastric sleeve

Background Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position was found to be a reliable method for the detection of TSH following gastric bypass (LRYGB). In the present study, our aim was to examine the incidence of TSH after gastric sleeve, and further to investigate the proportion of symptomatic trocar site hernias. Methods Seventy-nine patients subjected to laparoscopic gastric sleeve in 2011–2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey. Results The incidence of trocar site hernia was 17 out of 79 (21.5%), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no significant correlation between patient symptoms and a TSH. Conclusions The incidence of TSH is high after laparoscopic gastric sleeve, a finding in line with several recent studies as well as with our first trial on trocar site hernia after LRYGB. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of a trocar site hernia can be serious, the proportion of symptomatic TSH needs to be more clarified.

The “Flip-Flap” Technique for Laparoscopic Port-Site Closure—Description of a Novel, Cost-Effective Technique with Review of Literature

Overview Laparoscopic approach has changed the face of surgical care offered to patients. Almost all surgical procedures across specialties are now undertaken by the laparoscopic approach. Closure of port sites to prevent trocar-site hernias (TSHs) forms an integral part of the laparoscopic procedure. TSH is an area of preventable surgical morbidity. We hereby report our technique that is easily applicable, simple, safe, and highly cost-effective. It requires no additional instruments or retractors, is easy to learn, and has a very favorable safety profile. Materials and Methods This prospective case series enrolled a total of 454 port-site closures in 255 patients undergoing different laparoscopic procedures over a period of 2 years. The intraperitoneal tissue forceps were used in the reverse direction to lift the fascia up and a right-angled retractor was used to retract back the skin and subcutaneous tissue. The port-site closure is done under vision and no adverse events were reported. Results This technique was used in 454 port sites in 255 patients. No intraoperative incidents were noted. There is no requirement of any specialized instruments or retractors. No additional tissue trauma or dissection is required. There is no extension of operative time. The technique is simple to learn and easy to teach. No bowel injuries or TSHs were reported during a follow-up of 26 months. Conclusion The described technique is easy, simple, cost-effective, and has a good safety profile.