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Laparoscopic trocar site herniae
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  1. Gerrard O’Donoghue1,
  2. Bruce Mann2
  1. 1
    Royal Women’s Hospital/Royal Melbourne Hospital, Surgery, 382 Montague Street, Albert Park, Melbourne, Victoria, 3206, Australia
  2. 2
    Royal Women’s Hospital, Department of Surgery, 20 Flemington Road, Parkville, Melbourne, Victoria, 3052, Australia
  1. Gerrard O’Donoghue, gerodonoghue{at}rcsi.ie

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The abdominal contrast CT image demonstrates small bowel obstruction due to a 15 mm supraumbilical left para median anterior abdominal wall trocar site hernial defect (fig 1).

Figure 1

Contrast abdominal CT image 10 days post laparoscopic abdominal hysterectomy.

Trocar site herniae developing at trocar cannulation sites are a serious complication that may require additional unplanned surgery.1 As the role of laparoscopy increases and trocar sizes increase, the incidence and risk of hernia is rising. Tonouchi’s review of large series on digestive surgery trocar site herniae between 1995 and 2002 estimated the incidence to be 0.65–2.80%, but herniae are frequently under-reported as patients may be asymptomatic, lost to follow-up or be seen by alternative surgeons for hernia management.1

Early type presents within 2 weeks postoperatively, frequently with small bowel obstruction. Late type presents from 2 weeks to several months postoperatively, with an asymptomatic swelling. Special type presents acutely with peritoneal contents exposed.

Factors associated with trocar site hernia development include intra-abdominal pressure overwhelming abdominal wall strength, 10 mm (86%) trocar size,1 umbilical (75%) trocar site,2 trocar site fascial extension and aggressive manipulation,2 non-closure of sites >8 mm,1 non-deflation of pneumoperitoneum prior to trocar removal,3 co-morbidities and post operative wound infection.

Prevention is the key, with all trocar sites 8–10 mm or larger requiring closure1 and sites <5 mm in children requiring closure.2

Surgical management involves trocar site enlargement, peritoneal contents or hernial sac reduction, fascial defect closure with or without mesh re-enforcement. Small bowel resection is required if bowel viability has been compromised.1

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Footnotes

  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication.