Incisional bowel herniations after operative laparoscopy: A series of nineteen cases and review of the literature

Objectives

To identify all cases of incisional bowel herniation after operative laparoscopy in 11 participating institutions and to report the clinical details of such patients.

Study Design

A retrospective review of all cases of bowel herniation occurring after operative laparoscopy at the participating institutions during the study period was conducted. Patient age, original procedure, site and size of all trocars used, method of diagnosis, interval to second procedure, site of herniation and final outcome were recorded. No attempt was made to define the total number of operative laparoscopies performed at the participating institutions during the study period.

Results

Nineteen patients with 21 bowel herniations were identified. The average age of the patients was 50.5 years. Of the 21 herniations, 12 (57%) occurred at 12 mm lateral port sites. This complication has not been previously reported. Where specified (n=29), the size of the trocar site was 10 mm in nine patients (31%), 11 mm in one (3.4%), and 12 mm in 19 (65.5%). Umbilical herniations accounted for 12 of 33 herniations (36.3%), whereas extraumbilical sites were involved in 21 of 33 (63.6%). Six of the 31 cases (19.3%) have required small bowel resection. In addition to the bowel herniations, at least eight patients with omental herniation after laparoscopy have been reported. The average time to reoperation was 8.5 days.

Discussion

There are several reasons for the potential increase in incisional herniation: (1) the use of multiple ancillary ports, (2) extirpative procedures requiring larger ports for specimen removal, (3) newer instrumentation requiring 10 and 12 mm ports, (4) increased operating times with more port manipulation, and (5) use of port anchoring devices which may add an extra 1 to 2 mm to the fascial defect. The surgeon should use smaller trocars (5mm), if possible. When larger ports ( 10 mm) are used, an attempt should be made to suture the defect.

Conclusion

Incisional bowel herniation is a serious complication of operative laparoscopy. Herniations occur through ports 10 mm in size at both umbilical and extraumbilical sites. In spite of these precautions, surgeons should recognize the difficulty in actually closing fascia at these larger port sites and should maintain a high degree of suspicion in any patient who has a slow recovery with intermittent nausea and vomiting after an operative procedure.