Working Port-Site Hernias: To Close or Not to Close? Does It Matter in the Obese?

The Hole in the Wall with Samuel Szomstein, MD, FACS

This month’s topic: Working Port-Site Hernias: To Close or Not to Close? Does It Matter in the Obese?

by Edward Phillips, MD, FACS; David Santos, MD; and Shirin Towfigh, MD, FACS

Bariatric Times. 2011;8(6)24–30This column is dedicated to providing a venue for interactive exchange of ideas, interesting topics, and surgical pearls from experts in repair of abdominal wall defects as they relate to bariatric surgery

This Month’s Featured Experts: Edward Phillips, MD, FACS; David Santos, MD; and  Shirin Towfigh MD, FACS. All from Weight Loss Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California

A Message from Column Editor Samuel Szomstein, MD, FACS
Welcome to the second installment of “The Hole in the Wall.” The purpose of this column is to provide the readers of Bariatric Times with a venue for an interactive exchange of ideas, interesting topics, and surgical pearls from experts in the field of abdominal wall defect repair as they relates to bariatric surgery. We encourage your questions, ideas, and surgical scenarios in what we are certain will be an interesting and educational column. We are very honored to have Edward Phillips, MD, FACS, Director, Center for Minimally Invasive Surgery and Director of Endoscopic Surgery at Cedars-Sinai Medical Center, Los Angeles, California, as a guest expert. We welcome his expertise and comments in this month’s installment, “Working Port-Site Hernias: To Close or Not to Close? Does It Matter in the Obese?” The Answers to the mesh test, which appeared in our first installment, are also available here. We hope you enjoy our column, and we look forward to your questions, comments, and participation in future installments.

Working Port-Site Hernias: To Close or Not to Close? Does It Matter in the Obese?

Laparoscopic surgery has revolutionized surgical care for individuals with morbid obesity. Patients with morbid obesity who undergo laparoscopic surgery benefit from decreased post-surgical pain, shorter length of hospital stay, fewer wound-related complications, and fewer incisional hernias.[1] While the benefits of laparoscopy have been well characterized, the prevention, incidence, prevalence, and outcomes of incisional hernia at the working port sites are not commonly reported. Case studies report poor outcomes from port-site herniation, particularly from bowel incarceration, including death.26 Whether to suture close a port site and which size port to close has not been elucidated. Some experts suggest that port sites greater than 10mm, or even 5mm, be closed routinely while others do not close 15mm sites.[2] Currently, Level 1 evidence does not exist to support routine fascial closure, and many high-volume bariatric surgeons do not routinely close fascial defects from 5mm, 10mm, and 12mm trocars.[3–5]

This column will review the literature to determine the clinical presentation, diagnosis, incidence, and outcome of port-site herniation and evaluate the evidence that supports closing port sites during bariatric laparoscopic operations.
Trocar-site herniation occurs infrequently and is reported at 0.14–8.0 percent.[4,19] To date, it is unclear if closure of fascial defects is required. When considering the management of trocar sites in the patient with morbid obesity, the findings of thick omentum and short mesentery in this patient population should be considered to be protective from incarceration through small fascial defects. At the Cedars-Sinai Weight Loss Center of Excellence, Los Angeles, California, 12mm trocar sites are not routinely closed after gastric bypass, rather, they are closed selectively. For example, if a patient is found to have thin omentum, the surgeon may selectively close the 12mm trocar sites. All 15mm trocar sites are routinely closed.

Unfortunately, the literature does not provide conclusive evidence to support selectively closing 12mm trocar sites and routinely closing 15mm trocar sites. Thus, we reviewed our own experience and performed a systematic review of the current literature to define the incidence of trocar-site herniation among all patients undergoing laparoscopic bariatric surgery. The other purpose of this study was to identify the incidence of trocar site herniation based on whether the fascial defects are closed and to determine their outcomes.

Methods
Cedars-Sinai cohort. All patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) at Cedars-Sinai Medical Center between January 1, 2009, and December 31, 2009, were identified using the Cedars-Sinai Medical Weight Loss Center of Excellence database. Institutional Statistical Classification of Disease, Ninth Edition (ICD-9) codes for ventral or incisional hernia (551.2, 551.21, 552.2, 552.21, 553.2, 553.21) were used to select records for review. Patient charts were reviewed and only two documented trocar site hernias were identified and used for analysis. Data extracted included age, gender, body mass index (BMI), length of follow up, and surgical technique, including number and type of trocars placed and diameter of trocars used.

A PubMed search from 1985 to 2010 was performed using the search terms “trocar,” “port site,” and “hernia.” The search was restricted to articles in English and on human subjects. Seven-hundred and sixty-one articles were reviewed. Case reports, technique papers, and articles on single-incision laparoscopy, natural orifice surgery, endoscopy, open surgery, and thoracoscopy were excluded. The initial literature search failed to identify many major known studies regarding the outcomes of the three most popular bariatric procedures—LRYGB, laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). A second literature search using the same limits and the search terms “laparoscopic” and “gastric bypass,” “sleeve gastrectomy,” “gastric band,” and “outcome” identified 952 articles (Figure 1). Of these, 579 articles described case reports, single-incision laparoscopy, biliopancreatic diversion/duodenal switch (BPD-DS), ileal loop interposition, mini gastric bypass, vertical banded gastroplasty, open bariatric surgery, and the effect of bariatric surgery on psychosocial status or obstetrics were excluded. Of the 373 studies selected for review, 332 studies were excluded because they did not specifically mention port-site or incisional hernia in the body of the article. Systematic review was performed on 41 articles: 27 on RYGB (1 randomized control trial, 2 prospective studies, 25 retrospective studies), 10 on LAGB (3 prospective studies, 7 retrospective studies), and 4 on LSG (4 retrospective studies). Data were mined for the number of port-site hernias, BMI, number, size and type of trocars used, whether trocar sites were closed, when hernias occurred, and associated morbidity and mortality of port-site hernias. Articles and authors were cross referenced to ensure that data points were not counted more than once. A large American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) study by Lancaster[6] and two meta-analysis studies7,8 were eliminated from calculating the incidence of trocar-site hernia because of the potential for counting data points more than once. All corresponding authors of the 41 articles were contacted to provide additional information for this systematic review.

Case reports.

Patient 1. Patient 1 was a 60-year-old woman with a preoperative BMI of 36.9 kg/m2. She had obesity-related comorbidities of hypertension, dyslipidemia, and a past medical history of seizures, hiatal hernia, and Crohn’s disease. She underwent LRYGB using five 12mm bladeless trocars. Fascial defects from the trocar sites were not closed. The patient followed an expected postoperative course until Postoperative Day 3 when she began to complain of abdominal pain unrelieved by narcotic medication. Her oral intake was also noted to be decreased. She was noted to have asymptomatic hypotension without tachycardia as well. A computed tomography (CT) scan of the abdomen was obtained, which demonstrated a high-grade bowel obstruction secondary to a trocar-site hernia through the left anterolateral abdominal wall (Figure 3).

The laparoscopic approach was used to reduce the incarcerated loop of bowel. The bowel became immediately viable when released from the abdominal fascia, and a bowel resection was not required. The fascial defect was then closed with 0-Vicryl suture. Unfortunately, this patient’s postoperative course was complicated by heparin-induced thrombocytopenia, left upper extremity ischemia from pre-existing subclavian artery disease, and a mild cerebral vascular accident postoperatively.

In one year follow up, she lost 57 percent of her excess body weight (EBW) and now has a BMI of 29.3kg/m2. There have been no further consequences from her trocar-site hernia.

Patient 2. Patient 2 was a 51-year-old man with a preoperative BMI of 52kg/m2 and the obesity-related comorbidities of gastroesophageal reflux disease with with Barrett’s esophagitis, and the medical comorbidities of atrial fibrillation and chronic pain syndrome secondary to multiple spine surgeries. The patient underwent LRYGB using five 12mm bladeless trocars, and the trocar sites were not closed. The patient followed an expected postoperative course and was able to tolerate a liquid diet prior to discharge on Postoperative Day 3. Of note, he had a rather high narcotic requirement given his history of chronic pain syndrome. He missed two of his postoperative appointments due to social reasons, and reported to his internist with complaints of cellulitis at his inferior, left, upper quadrant trocar site (Figure 4). On further questioning, he stated that he had not had flatus or bowel movements for 15 days.

His history of bowel obstruction prompted a CT scan of the abdomen and pelvis to rule of intra-abdominal or subcutaneous tissue abscess versus a trocar-site hernia. The CT scan confirmed a high-grade small bowel obstruction, and the patient was explored laparoscopically (Figure 5). At the time of surgery, strangulated small bowel and pus was noted in the lowermost left paramedian trocar site. The small bowel was resected and a primary anastomosis was performed. The fascial defect was closed with an 0-Vicryl, and the skin and subcutaneous tissue were managed with wet-to-dry dressings.

Postoperatively, the patient remained on intravenous antibiotics. Wound cultures grew Enterococcus species and fungus, consistent with intestinal flora. After this incident, the patient was able to tolerate liquid diet and return to regular bowel function. Longer term-data regarding his weight loss is pending.

Results
Analyzing the 40 articles that met criteria for review, 16 articles specifically mentioned whether surgeons closed trocar sites. Twenty-four authors did not mention how trocar sites were handled, but did report postoperative trocar-site hernia rates. The overall incidence of trocar site herniation was 0.97 percent (Table 1). If the fascia was closed, the incidence of trocar-site herniation was 0.96 percent (not closed) versus 0.42 percent (closed, P< 0.02).

In the laparoscopic RYGB subpopulation, the incidence of trocar-site hernia was 1.1 percent. The BMI average range was 41 to 60kg/m2. If the fascia was closed, the incidence of trocar-site herniation was 1.1 percent (closed) versus 0.36 percent (not closed, P<0.01).

In the LSG and LAGB subpopulation, the incidence of trocar-site hernia was 0.63 percent. The BMI average range was 39 to 49kg/m2. The trocar configurations for both of these procedures are similar in that they require a similar number of trocars and at least a 15mm trocar, or a 12mm trocar fascial defect is widened in order to remove the stomach remnant or implant the adjustable gastric band device. Thus, these two procedures were considered together as a single subpopulation to increase total numbers for better statistical power. The incidence of trocar-site herniation was 0.8 percent if the fascia was closed and 0.62 percent if fascia was not closed. These findings were not significant.
Port-site hernias were reported in 124 patients: 26 uncomplicated, 14 complicated, and 84 with unknown outcomes. Of the 26 uncomplicated hernias, two were observed and 24 were treated with incisional hernia repair (Figure 2). All 14 complicated hernias were treated surgically. One patient required small bowel resection, one required colonic repair, and one patient died of multi-organ system failure directly resulting from bowel strangulation (Figure 2). Time to development of trocar site hernia was recorded in nine studies. All three complicated hernias (100%) occurred before Postoperative Day 30, whereas 5 of 6 uncomplicated hernias (87%) occurred after Postoperative Day 30.
All other parameters examined (e.g., sizes of trocars used, type of trocars, and where the trocar-site hernia occurred) were not reported or not reported in adequate numbers to draw any conclusions.

Discussion
Since the introduction of laparoscopic weight loss surgery, only 41 articles reported results of trocar-site herniation. In our systematic review, the incidence of trocar site herniation was 0.96 percent (0.14–8.0%) of trocar-site herniation reported in literature (Table 2). This is consistent with the incidence reported in the study by Lancaster[6] of 4,756 patients using ACS-NSQIP data (1.1% vs. 0.99%).

In addition to trying to determine the incidence of trocar-site herniation, we questioned whether closing trocar-site fascia affects the trocar-site hernia rate or the incidence of complicated hernia. Surprisingly, we found that in the LRYGB patients, closure of trocar sites is associated with a significantly higher incidence of trocar-site herniation (1.1% vs. 0.36%). Reasons for this outcome are not clear. It could be that surgeons who close sites examine for the presence of hernia more assiduously or the technique of closure may contribute. Fascial closure of trocar sites in patients with morbid obesity is often difficult and inadequate.  The inherent difficulty in placing transfascial stitches precisely with a suture passer can result in incomplete closure of the fascia or increase damage to already traumatized tissue. Also, it is possible that suture closure results in tissue ischemia or cutting/tearing when the wound swells or the patient’s intra-abdominal pressure increases during a cough or straining; both mechanisms could result in a larger fascial defect.

In contrast, in the LSG/LAGB subpopulation, closure of the trocar site(s) did not infer a significant difference in hernia rates (0.80% vs. 0.62%). The possible explanation of this finding is that LSG and LAGB requires a 15mm trocar and the fascia is widened to accommodate the stomach or the band. This is in comparison to 12mm trocars placed in LRYGB where the fascia is not intentionally widened except when dilated to accomodate a circular stapler. When analyzing the patients where the fascial defects are not closed, the incidence of trocar-site herniation is higher in LSG/LAGB versus LRYGB (0.62% vs 0.36%). When fascia is closed, the rates of hernia are similar between the two sub-populations. The incidence of trocar-site herniation in LSG/LAGB patients calculated from our systematic review is higher than the rates reported by the meta-analyses on LAGB performed by Chapman7 and Vella8 (0.63% vs. 0.15% and 0.03%). It is unclear why this disparity exists; however, these meta-analyses are older studies, and more trocar-site hernias may have been reported over time or bladed trocars could have been used. Also, there may be a greater appreciation of trocar-site hernias and their complications in patients with morbid obesity since outcomes reporting is required for Center of Excellence (COE) certification.

This study provides the most exhaustive search for trocar-site hernias in the published literature. It became very clear to us that trocar site hernias are not easily searchable and are clearly under-reported. This is even among the population of patients with morbid obesity, who represent an ideal population to study outcomes as large databases exist and mandatory follow up is tightly regulated in bariatric Centers of Excellence.

The weaknesses of our study and systematic literature reviews include the heterogeneity of operative technique, follow-up time variation without clear notation of exam for hernia, and type of studies that report trocar hernia rates. For example, not all authors reported details of the sizes and types of trocars that were utilized. The effect of trocar type, such as bladed, nonbladed, and radially expanding, may play a role in the development of hernias as these devices result in varying fascial defects.[11] Also, the location of the trocar-site hernias was not always mentioned, and some authors routinely closed fascial defects in the midline, but left other defects open in the lateral abdomen where there are several layers of musculature.[3,5] Thus, heterogeneity in technique was found even within the same patient.

The assumption has been that hernias occurred at the larger trocar sites; however, case reports in urology and gynecology have reported incarceration even in 5mm trocar sites.44 Secondly, length of follow up was not consistent across all studies since the majority of studies were retrospective. The true incidence of trocar-site herniation may not be known until five years postoperatively, thus underestimating the incidence currently reported.[9] Furthermore, a complicated hernia usually presents as a surgical emergency, and it is possible that the original surgeon is uninvolved and unaware of this complication. Thus, the true incidence of trocar-site hernia may be further underestimated. A very important note, however, is that in our experience and, as shown in our systematic review, all complicated hernias occurred early postoperatively. While this could be bias of follow up, our hospital is a large community teaching hospital and we have a bariatric surgery emergency service. We operate on many bariatric patients from all over the region and have not operated emergently on another surgeon’s complicated trocar-site hernia. The implication is that complication from trocar-site hernia occurs early and the primary surgeon is usually involved.

Our recommendation is to maintain high vigilance and suspicion when evaluating patients who have recently undergone laparoscopic weight loss surgery. The early signs of a complicated port-site hernia can be excessive pain, swelling at the site, and discoloration similar to a hematoma. Intermittent or complete bowel obstruction may occur later in the presentation. Delay in diagnosis is common, requiring emergency surgery, bowel resection, and can result in death. Clinical suspicion and the liberal use of CT scanning can help make the diagnosis.

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Tags: hernia repair, working port-site hernias

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