Strategies for preventing port-site hernia following robot-assisted radical prostatectomy: a systematic review

Abstract

Background: Trocar site hernia is a recognized but often underreported complication of minimally invasive surgery, including robotic-assisted radical prostatectomy. While relatively rare, trocar site hernia can lead to severe complications such as bowel obstruction, strangulation, and the need for emergency surgical intervention. Trocar size has been identified as a primary risk factor, with hernias occurring predominantly at sites where 10 mm or larger trocars are used. However, the role of fascial closure is still debated.

Methods and results: A systematic literature review (1992-2022) identified 21 cases of trocar site hernia in 13 studies. Only 8 papers provided data on the total number of RaRP procedures which were associated to the reported cases of TSH, with 15 cases of TSH identified out of 3,418 RaRP procedures. Statistical analyses were conducted to assess significant risk factors and potential prevention strategies. Specifically, of the 19 cases in which trocar size was explicitly reported, 15 hernias were associated with 12 mm trocars and 4 with 8 mm trocars (p<0.001). Fascial closure was not performed in all reported cases involving 12 mm trocars. No significant correlations were found between trocar site hernia incidence and patient-related factors such as age, body mass index, or prior hernias. Additionally, we report a case of trocar site hernia following RARP in a 67-year-old male with a BMI of 33.46 and a history of prior abdominal hernioplasty. The patient developed bowel obstruction on postoperative day 4 due to a hernia at a 12 mm trocar site, requiring emergency laparotomy and bowel resection with end-to-end anastomosis.

Conclusions: Given the strong association between TSH and 12 mm trocars, we suggest routine fascial closure at these sites to reduce the risk of postoperative complications. Further studies are necessary to confirm these findings. Additionally, other potential risk factors and mechanisms contributing to trocar site hernia development in patients undergoing robot-assisted radical prostatectomy should be investigated.