Port site implants have been reported after laparoscopy since the prevideo era in the 1970s and 1980s.[3, 6, 11]. When video capabilities were added, and as the surgeon’s expertise increased, the indications for laparoscopy broadened and the number of patients undergoing laparoscopic interventions increased rapidly. Several reports showed that patients with intraabdominal cancers were at risk of developing port site implants. [1, 2, 4, 9]. In spite of the risk of this adverse event, because of it’s well-documented advantages in terms of better cosmetic results, shorter hospital stay, and improved immune response to injury, video laparoscopy has become a valuable technique for the staging and treatment of intraabdominal malignant tumors [14]. Technical advances and increased skill have decreased the risk of port site implants to a minimum in patients with known malignancy [10]. However, port site seeding remains a problem for patients in whom intraabdominal malignancy is not suspected and who undergo a laparoscopic procedure, possibly because insufficient precaution is taken to avoid the seeding of cancer cells [7, 15]. Port site implants may themselves become the source for new metastasis.

We present a case of lymph node metastasis from port site implants after laparoscopic cholecystectomy for cholelithiasis in a patient unknown to have a right colon cancer.

Case report

A 42-year-old man had a history of nodular sclerosing Hodgkin’s disease that was diagnosed and treated with systemic chemotherapy at age 24. One year prior to his treatment at out institution, he had developed periumbilical pain, that was colicky in nature, and worsened by ingestion and was accompanied by borborygmi. After ultrasound showed cholelithiasis, he underwent a laparoscopic cholecystectomy. One month later, because the pain had continued, a colonoscopy was performed, revealing a right colonic adenocarcinoma. The patient had an uneventful, potentially curative right colectomy. No peritoneal seeding was found at the time of the operation. The pathology report confirmed a poorly differentiated mucinous adenocarcinoma with signet ring morphology and five of 15 positive lymph nodes (T4 N2 Mx). The patient received systemic postoperative chemotherapy with irinotecan, 5-fluroruracil, and leucovorin for four cycles.

Eleven months after the colonic resection, he had a CT scan because of right upper quadrant pain. It showed two small nodules on the left lateral segment of the liver, which were proven to be metastatic adenocarcinoma by percutaneous biopsy. It also showed a nodule in the umbilical area of the abdominal wall (Fig. 1) and a nodule behind the right rectus abdominis muscle, adjacent to the right deep epigastric vessels (Fig. 2).

Figure 1
figure 1

Nodule immediately adjacent to the umbilicus. The CT cut shows a mass just beneath and slightly to the right side of the umbilicus. In greatest dimension, it is approximately 2.5 cm. It is indicated by an arrow.

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Figure 2
figure 2

Enlarged right deep epigastric lymph node. The 1.5 cm mass beneath the right rectus muscle has been indicated by an arrow. No adenopathy was present on the left side.

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The patient underwent combined treatment with cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy. Peritonectomy procedures and wedge liver resection for segment III liver metastasis made him macroscopically disease free. During the procedure, hard nodules were found and resected in the periumbilical, epigastric, and right upper quadrant port sites. The right deep epigastric nodule seen on CT scan was also removed.

The pathology report confirmed metastatic adenocarcinoma in all of the port sites. The right deep epigastric nodule was reported to be a lymph node involved with metastatic disease.

Discussion

As a result of direct wound implantation, probably because of instrument contamination and the chimney effect, this patient developed tumor nodules in all port sites. The abdominal wall was involved in its full thickness at the trocar sites. Deep epigastric lymph nodes receive the lymphatic drainage of the abdominal wall, via the lymphatic channels along the epigastric vessels [5]. In this patient, metastatic disease was found in one of the deep epigastric lymph nodes, and the only sites of cancer in the abdominal wall were the port site implants. It is probable that dissemination of cancer cells to this lymph node occurred from the port site implants. To the best of our knowledge, this event has not been previously reported in the literature.

Metastases to regional lymph nodes from port site implants are likely to go under diagnosed, unless the surgeon is aware of this possibility. Patients with port site implants should be examined not only for peritoneal carcinomatosis but also for the presence of metastases in the lymph nodes draining the abdominal wall. The anatomic sites that are at risk for lymph node metastases can be predicted from the anatomic location of the port site. Infraumbilical superficial lymphatic drainage follows epigastric vessels draining into inguinal lymph nodes. Vessels going to axillary and parasternal lymph nodes drain the superficial supraumbilical region. Lymphatic drainage from the deep upper anterior abdominal wall runs with the superior epigastric vessels to the parasternal nodes and that of the deep lower anterior abdominal wall ends in the circumflex iliac, inferior epigastric, or external iliac lymph nodes [5]. If a port site implant is observed, the appropriate axillary, parasternal, inguinal, deep epigastric, and iliac lymph nodes should be assessed for metastases. Both physical examination and CT scan should be used to detect enlarged nodes. Also, at the time of exploratory surgery, the appropriate lymph nodes groups should be palpated and biopsied if thought to be abnormal. Because lymphatic drainage can be unpredictable, for patients undergoing resection of a port site implant, radio-guided mapping of lymph nodes could accurately indicate the lymph node basins at risk [8].

More attention should be paid to the outcome in terms of recurrence and survival of patients who are observed to have port site implants. The literature contains many studies on the mechanisms and prevention of port site metastasis, but there are very few publications that address the treatment and outcome of these patients.

Successful management of limited carcinomatosis from colonic cancer has been reported [12, 13]. In our experience, the outcome of patients with carcinomatosis who also have port site metastases has been similar to that for patients with carcinomatosis only, so long as the port site disease has been resected (unpublished data).

Isolated port site recurrence may occur; more commonly, it is observed along with carcinomatosis. From an etiologic perspective, the surgeon must always suspect that port site cancer indicates a generalized peritoneal contamination. If port site recurrence is to be treated by surgical extirpation, a full abdominal exploration through an abdominal incision is recommended to diagnose and then definitively manage the carcinomatosis.