Journal of Robotic Surgery

, Volume 8, Issue 1, pp 89–91 | Cite as

Trocar-site hernia at the 8-mm robotic port after robot-assisted laparoscopic prostatectomy: a case report and review of the literature

  • James Hok-Leung Tsu
  • Ada Tsui-Lin Ng
  • Jason Ka-Wing Wong
  • Edmond Ming-Ho Wong
  • Kwan-Lun Ho
  • Ming-Kwong Yiu
Case Report

Abstract

Trocar-site hernia is an uncommon but serious complication after laparoscopic surgery as it frequently requires surgical intervention. We describe a 75-year-old man with Gleason score 4 + 3, clinical stage T1c prostate adenocarcinoma who underwent an uneventful robot-assisted transperitoneal laparoscopic radical prostatectomy. On post-operative day four, he developed symptoms of small bowel obstruction due to herniation and incarceration of the small bowels in a Spigelian-type hernia at the left lower quadrant 8-mm trocar site. Surgical exploration was performed via a mini-laparotomy to reduce the bowel and repair the fascial layers. A literature search was performed to review other cases of trocar-site hernia through the 8-mm robotic port after robot-assisted surgery and the suggested methods of prevention.

Keywords

8-mm port Robot-assisted laparoscopic prostatectomy Trocar-site hernia 

Introduction

The introduction of the robotic surgical system has revolutionized the field of minimal invasive surgery. Its many advantages have made the robot-assisted approach the preferred method in various urologic procedures, including radical prostatectomy. In our team’s experience of more than 200 robot-assisted laparoscopic radical prostatectomies (RALPs), we recently encountered our first case of trocar-site hernia (TSH). It involved the 8-mm robotic port and the patient required re-operation. Here we describe this case and review the literature on TSH involving the 8-mm robotic port after robot-assisted laparoscopic surgery.

Case report

A 75-year-old man presented with a prostate-specific antigen level of 5.4 ng/ml. He has known psoriasis undergoing medical treatment and history of bilateral open inguinal herniorrhaphy with recurrence on the left side necessitating a subsequent laparoscopic hernioplasty. Transrectal ultrasound-guided prostate biopsy revealed Gleason score 4 + 3, clinical stage T1c prostate adenocarcinoma. The prostate volume was 28.7 cm3. After discussing with him the treatment options including surgery, radiotherapy and active surveillance, he was very keen on radical surgery. In view of his Gleason sum of 4 + 3, it was decided that a pelvic lymphadenectomy was indicated. Using a 6-port transperitoneal approach described by Pick et al. [1], RALP with bilateral pelvic lymphadenectomy was performed uneventfully. The 12-mm periumbilical port for the camera was enlarged at the end of the procedure for specimen retrieval. This enlarged port site and the 12-mm assistant port at the right lower quadrant were closed with polydiaxanone at the fascial levels. The three 8-mm robotic arm ports and the 5-mm assistant port were closed only at the skin level. He was resumed on full diet on post-operative day 2 and was discharged on day 3.

On post-operative day 4, he noted abdominal pain and distension, particularly over his left lower quadrant, together with anorexia and vomiting. He was readmitted and physical examination revealed a distended abdomen with a notable tender bulge beneath the left-sided 8-mm robotic port scar (Fig. 1). Abdominal radiographs revealed dilated small bowel loops with fluid levels and computer tomography demonstrated herniation of bowel loops through a defect in the fascial layers and peritoneum at the left 8-mm port site (Fig. 2). There was proximal dilatation of the small bowels indicating the presence of incarceration and obstruction. A mini-laparotomy over the 8-mm port site was performed. On exploration, the external oblique was intact but a loop of small bowel, dusky in color, was found to herniate through the peritoneal and internal oblique defect and was trapped between the internal and external oblique. After enlargement of the internal oblique defect and warm packing of the bowels, a pink color returned and no bowel resection was necessary. The bowel loops were returned to the peritoneal cavity with the subsequent mini-laparotomy wound closed in separate fascial layers using polydiaxanone. The patient made an uneventful recovery from the reoperation and was discharged on post-laparotomy day 7.
Fig. 1

Patient on presentation with intestinal obstruction, with a bulge at the left lower quadrant. Arrow points to the 8-mm robotic port site

Fig. 2

Contrast computed tomography image showing herniation of the bowel through the peritoneal and internal oblique defect at the 8-mm trocar site

Discussion

TSH is defined as the development of a hernia at the cannula insertion site after laparoscopic surgery [2]. It was first reported by Fear in 1968 and since then in all surgical specialties that utilize laparoscopy [3]. The overall incidence of TSH ranges from 0 to 5.2 % but the true incidence may be higher due to under-diagnosis or under-reporting [4]. Many factors have been implicated as predisposing to TSH formation (Table 1). Regarding trocar size, TSH has been reported at ports sized 5 mm or even smaller [5]. Fascial closure has been advocated to prevent TSH but TSH has been reported despite seemingly complete fascial closure [6]. Finally, TSH has been reported despite the use of bladeless, radially dilating trocars, specially designed to decrease the size of muscular and fascial defect [7]. In short, the use of smaller ports, closing the fascial defect and special trocar designs might help decrease the incidence of TSH but none of these measures can completely prevent its occurrence.
Table 1

Factors reported to predispose to trocar-site hernia after laparoscopic surgery

Patient-related factors

 Age

 Body mass index

 Wound infection

Technical factors

 Trocar size

 Fascial closure

 Trocar design

 Technique of pneumoperitoneum establishment

 Port location

 Type of suture for fascial closure

The use of robots is gaining increasing acceptance in the field of laparoscopic surgery. Besides the usual 12-mm ports, robot-assisted laparoscopic procedures utilize two or three 8-mm reusable ports for the robotic instruments and these can be introduced using either sharp or blunt obturators. Our literature search yielded four reported cases of TSH from the 8-mm robotic port site (Table 2) [8, 9, 10]. The fact that three of the four reported cases arose after RALP may simply be due to the high prevalence of the procedure. It is evident that such TSH after robotic surgery is serious because all but one of the reported cases of TSH presented acutely with intestinal obstruction and all cases required surgical intervention. In all four cases of TSH, the robotic port sites were left open without fascia closure after the primary procedure. In traditional laparoscopic surgery, since there are technical difficulties in closing the fascia of ports smaller than 10 mm (5-mm ports), laparoscopic surgeons generally do not close the fascia of these ports. However, the robotic arms are known to create large torque in the abdominal wall [8]. This, coupled with the fact that an 8-mm trocar does create a larger fascial and muscular defect than the usual 5-mm trocar, may explain why TSH occurred in our patient after RALP. Furthermore, our patient’s musculature can be regarded as “hernia-prone” as he had a history of recurrent inguinal hernia after open herniorrhaphy. It remains controversial whether the fascia of the 8-mm ports should be routinely closed after robotic surgery. Our case is very similar to the one reported by Spaliviero et al. [9] in which the external oblique was found to be intact on exploration and the bowels herniated through the inner layers into a Spigelian type of hernia. Hence, simply closing the external oblique at the 8-mm port site appears inadequate to prevent TSH after robotic surgery. On the other hand, complete layered closure in an 8-mm wound usually requires enlargement of the skin incision, thereby undermining the benefits of the minimally invasive approach. Seamon et al. [8] advocated inserting Surgical (Ethicon Endo-Surgery, Cincinnati, OH, USA) plugs into the fascial defects at the 8-mm port site when fascia closure is not performed. Spaliviero et al. [9] recommended inserting the 8-mm port at a steep (60–90°) angle to avoid creating an excessively large fascial defect and preperitoneal space. They also suggested fascial closure only in patients with predisposing risk factors for hernia development. No report is available about the efficacy of these measures. As a result of this case, we now adopt a case-by-case approach in which complete closure of all layers at the 8-mm port will only be adopted for patients at high risk for TSH formation, e.g. previous history of inguinal or incisional hernia, patients with chronic cough or constipation. Otherwise, the 8-mm robotic port will only be closed at the skin level.
Table 2

Reported cases of trocar-site hernia at the 8-mm robotic port after robot-assisted laparoscopic procedures

Reference

No.

Procedure

Trocar obturator

Fascial closure

Presentation

Management

Seamon et al. [8]

1

Robot-assisted laparoscopic hysterectomy

Blunt

No

Small bowel obstruction on day 4

Emergency reduction and repair

Spaliviero et al. [9]

2

RALPa

Not specified

No

Small bowel obstruction on day 14

Emergency bowel resection and repair

Fuller et al. [10]

3

RALPa

Not specified

No

Omental evisceration from port site

Emergency excision of eviscerated omentum and repair

 

4

RALPa

Not specified

No

Asymptomatic TSH noted on follow-up

Elective repair

Present report

5

RALPa

Sharp

No

Small bowel obstruction on day 4

Emergency reduction and repair

aRALP robot-assisted laparoscopic radical prostatectomy

Notes

Conflict of interest

None.

Consent section

Written informed consent was obtained from the patient for publication of this Case Report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

References

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Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  • James Hok-Leung Tsu
    • 1
  • Ada Tsui-Lin Ng
    • 1
  • Jason Ka-Wing Wong
    • 1
  • Edmond Ming-Ho Wong
    • 1
  • Kwan-Lun Ho
    • 1
  • Ming-Kwong Yiu
    • 2
  1. 1.Division of Urology, Department of Surgery, Li Ka Shing Faculty of MedicineUniversity of Hong KongHong KongHong Kong SAR
  2. 2.Department of SurgeryUniversity of Hong KongHong KongHong Kong SAR

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