A Case of Incarcerated Hernia at the 5mm Port Site After Removal of Tube Drain

Takayuki Iino, MD, Hideto Oishi, MD PhD, Takao Yamane, MD, Eiichi Hirai, MD PhD, Shingo Kameoka, MD PhD, Masaki Fukunaga. YACHIYO MEDICAL CENTER, TOKYO WOMEN’S UNIVERSITY

 

INTRODUCTION-
Laparoscopy became a popular tool in gastrointestinal surgery. Laparoscopic operations offer an advantages of post-operative recovery and applications of this technique is still expanding. Parallel to the development of new technique, it will also expose patients to new complications. Port site hernia is one of new complications and several cases have been reported, recently. To prevent hernias, trocar sites 10mm or greater in size are recommended to close at the fascial level and 5mm trocar sites are usually closed only at the subcutaneous level because of the difficulty of exposing the fascia through the small skin incision and the rarity of herniation through these trocar sites. We herein report a rare case of an incarcerated hernia through a 5mm laparoscopic wound.

CASE REPORT-
A 86-year-old lady underwent laparoscopic-assisted left hemi-colectomy due to descending colon cancer. Five ports were used for carrying out the procedure, of which two were 10mm, two were 5mm, and 12mm for camera port. During closing, an 8 Fr tube drain was placed through the 5mm port at the upper left quadrant trocar site. On the fourth post-operative day, tube drain was removed. After 5 hours, the patient felt slight pain at the upper left quadrant and had small bulge without inflammation by the trocar site.
USG abdomen and CT scan revealed a viable herniating loop of small bowel with tight constriction at its neck. She was taken up for emergency operation. The port site incision that had been made on the left lower quadrant was transversely extended to about 5cm long. The length of incarcerated small bowel was about 10cm long and found to be viable. The small intestine was carefully placed back manually and hernia site were closed with absorbable polydioxanone 3-0 suture. After the operation, the patient made an uneventful recovery.

DISCUSSION-
Port site hernia is a rare complication following laparoscopic surgery. The incidence of trocar site hernia is estimated to be between 0.65-2.80%. Tonouchi et al, suggested a classification in which these hernias were classified into three types. The early-onset type occurs immediately after the operation, the late-onset type develops after several months and the special-type presents as dehiscence of the whole abdominal wall. Factors associated trocar site hernia development include intra-abdominal pressure overwhelming abdominal wall strength, 10mm(86%) trocar size, imcomplete closure of fascia at the trocar site, midline trocars, trocar site fascial extension, obesity and aggressive manipulation and post-operative wound infection. Prevention is the key, with all trocar sites more than 10mm at the fascia level and sites less than 5mm in infants requiring closure. In our case, peritoneal defect and fascial defect was lined straight due to placement of tube drain and weak fascia due to high age enlarged the defect and made possible for intestine to herniate.

CONCLUSION-
Hernia at 5mm laparoscopic port site is extremely rare, but attention should be paid to a possible occurrence of the hernia. Every effort should be done to repair the fascial and peritoneal defects to prevent the port site hernia.


Session Number: Poster – Poster Presentations
Program Number: P302
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