Small bowel obstruction secondary to herniation: Avoiding trocar injuries

Maintaining the right angle. Surgeons often take a wrong view–literally–of a step that enables them to insert the trocar through the least amount of tissue.

The step simply is to ensure that the secondary trocars enter at a right angle to the abdominal wall. Many Ob/Gyns begin at that angle, but then look up at the video monitor to watch the trocar pass through the peritoneum. In the process, they inadvertently move their hands so that the trocar follows a tangential angle. This increases both the amount of space through which the trocar must travel and the probability of a vessel injury.

To avoid this pitfall, keep your eye on the external abdominal wall so that the trocar remains at right angles, and have your assistant watch the screen to see when the trocar begins to impinge on the peritoneum. Once its tip enters the peritoneum, you can watch the video monitor as you pass the trocar intraperitoneally.

Think small. Use the smallest trocar capable of accomplishing the task at hand. Routinely using 12-mm trocars when you could use a 5-mm port will more than double the size of the entrance point and proportionally increase the risk of vascular injury and incisional hernias.

Herniation of small bowel through a fascial defect at a trocar insertion site is a rare but potentially serious complication. It occurs most frequently when large-diameter trocars are used, so the fascial defect should be closed whenever trocars larger than 5 mm are employed. You can close the fascia under direct vision or use a closure device. When the trocar sleeve is withdrawn, open the valve to prevent negative pressure from drawing bowel into the wound.

When a patient presents with a simple fascial defect at a trocar site, an elective repair can be performed in the usual manner. However, it is inappropriate to treat conservatively the patient who presents 3 to 7 days after laparoscopy with projectile vomiting, a distended abdomen, a tender nodule at a trocar site, and radiographic studies demonstrating dilated loops of small bowel, multiple air fluid levels, and an absence of rectal gas. Such patients have an incarcerated hernia that is producing a small bowel obstruction and must be treated surgically.