Incisional hernias after major laparoscopic gynecologic procedures

Abstract

Objective: Our purpose was to determine the incidence of incisional hernias after operative laparoscopy.

Study design: A retrospective case review was performed.

Results: The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was one in 429 (0.23%) cases and five in 161 (3.1%) cases, respectively; the difference is statistically significant (p = 0.007, Fisher's exact test). Incisional hernias were also significantly more common if the fascia was left open (p = 0.021), although three of the five hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia.

Conclusion: The underlying fascia should be closed whenever a 10 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites if the trocar is placed through, rather than lateral to, the rectus sheath.

PIP: For 2 decades a 2-puncture technique has been used for diagnostic laparoscopy and laparoscopic sterilization. The laparoscope is inserted through a 10-12 mm trocar at or just below the umbilicus, and a probe, monopolar or bipolar forceps, or a clip or ring applicator is inserted through a 5 mm trocar in the lower abdomen. A retrospective case review was performed with the purpose of determining the incidence of incisional hernias after operative laparoscopy. The combined number of trocars were stratified by size, site, and by whether the underlying fascia had been closed. In many cases only the charts were reviewed and the patients were not followed, so that the frequencies are minimal values. There were 6 (.17%) incisional hernias among 3560 operative laparoscopies, and all occurred at extraumbilical sites. The frequency of incisional hernias was significantly higher for 12 mm than for 10 mm trocars (p = 0.01). The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was 1 in 429 (.23%) cases and 5 in 161 (3.1%) cases, respectively; the difference was statistically significant (p = 0.007, Fisher's exact test). Incisional hernias were also significantly more common if the fascia was left open (p = 0.021), although 3 of 5 hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia. The underlying fascia should be closed whenever a 1 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites, if the trocar is placed through, rather than lateral to, the rectus sheath. In 3 of 5 cases involving 12 mm cannulas the surgeon attempted to close the fascia, which caused particular concern.