Robotic-assisted versus conventional laparoscopic surgery for endometrial cancer: long-term results of a randomized controlled trial.

BACKGROUND: Robotic-assisted laparoscopy has become a widely and increasingly used modality of minimally invasive surgery in the treatment of endometrial cancer. Due to its technical advantages, robotic-assisted laparoscopic surgery offers benefits, such as a lower rate of conversions compared to conventional laparoscopy. Yet, data on long-term oncological outcomes after robotic-assisted laparoscopy is scarce and based on retrospective cohort studies only. OBJECTIVE: This study aimed to assess overall survival, progression-free survival, and long-term surgical complications in patients with endometrial cancer randomly assigned to robotic-assisted or conventional laparoscopy. STUDY DESIGN: This randomized controlled trial was conducted at the Department of Gynecology and Obstetrics of Tampere University Hospital, Finland. Between 2010 and 2013, 101 patients with low-grade endometrial cancer scheduled for minimally invasive surgery were randomized preoperatively 1:1 either to robotic-assisted or conventional laparoscopy. All patients underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy. A total of 97 patients (49 in the robotic-assisted laparoscopy group and 48 in the conventional laparoscopy group) were followed up for a minimum of 10 years. Survival was analyzed using Kaplan-Meier curves, log-rank test, and Cox proportional hazard models. Binary logistic regression analysis was used to analyze risk factors for trocar site hernia. RESULTS: In the multivariable regression analysis, overall survival was favorable in the robotic-assisted group (hazard ratio 0.39; 95% confidence interval [CI], 0.15-0.99, P=.047) compared to the conventional laparoscopy group. There was no difference in progression-free survival (log-rank test, P=.598). The 3-, 5-, and 10-year overall survival were 98.0% (95% CI, 94.0-100) vs 97.9% (93.8-100), 91.8% (84.2-99.4) vs 93.7% (86.8-100), and 75.5% (64.5-87.5) vs 85.4% (75.4-95.4) for the conventional laparoscopy and the robotic-assisted groups, respectively. Trocar site hernia developed more often for the robotic-assisted group compared to the conventional laparoscopy group 18.2% vs 4.1% (odds ratio 5.42, 95% CI, 1.11-26.59, P=.028). The incidence of lymphocele, lymphedema, or other long-term complications did not differ between the groups. CONCLUSION: The results of this randomized controlled trial suggest a minor overall survival benefit in endometrial cancer after robotic-assisted laparoscopy compared to conventional laparoscopy. Hence, the use of robotic-assisted technique in the treatment of endometrial cancer seems safe, though larger randomized controlled trials are needed to confirm any potential survival benefit. No alarming safety signals were detected in the robotic-assisted group since the rate of long-term complications differed only in the incidence of trocar site hernia.

Trocar-site incisional hernia after 8-mm robotic trocar placement: A prospective study.

BACKGROUND: The current literature supports the closure of trocar sites ≥10-mm for the risk of developing incisional hernias, while there is no need to suture the abdominal fascia when using 5-mm trocars. To date, evidence regarding the closure of 8-mm trocars that are use by new robotic systems is weak. The aim of our study was to investigate the incidence of incisional hernia for 8-mm trocars. METHODS: We prospectively collected data on all patients undergoing robotic-assisted abdominal wall surgery from 2020 to 2023, in whom the abdominal fascia of all 8-mm trocars was not closed. The enrolled patients underwent a follow-up visit during which we conducted clinical and sonographic evaluations of all 8-mm trocars, in addition to assessing the satisfaction levels of the patients. The primary outcome was the incidence of port-site hernia. RESULTS: We enrolled 166 patients, 155 men and 11 women, for a total of 513 trocars accessed. Mean age was 61.1 ± 14.0 years, and mean BMI was 27.0 ± 3.9 kg/m2. The follow-up visits were carried out after a median follow-up of 14.5 (9.0-23.2) months. Only one case developed an asymptomatic 1 × 1 cm supra-umbilical hernia that was not treated. Patient reported a satisfaction regarding the 8-mm trocars and skin sutures of 9.8 ± 0.5 out of 10 points. CONCLUSIONS: The occurrence of a trocar-site hernia after 8-mm robotic access is extremely low. Hence, the fascia closure may not be necessary.

Bladed and bladeless conical trocars do not differ in terms of caused fascial defect size in a Porcine Model.

INTRODUCTION: Trocar insertion during laparoscopy may lead to complications such as bleeding, bowel puncture and fascial defects with subsequent trocar site hernias. It is under discussion whether there is a difference in the extent of the trauma and thus in the size of the fascia defect between blunt and sharp trocars. But the level of evidence is low. Hence, we performed a Porcine Model. METHODS: A total of five euthanized female pigs were operated on. The average weight of the animals was 37.85 (Standard deviation SD 1.68) kg. All pigs were aged 90 ± 5 days. In alternating order five different conical 12-mm trocars (3 × bladeless, 2 × bladed) on each side 4 cm lateral of the mammary ridge were placed. One surgeon performed the insertions after conducting a pneumoperitoneum with 12 mmHg using a Verres' needle. The trocars were removed after 60 min. Subsequently, photo imaging took place. Using the GSA Image Analyser (v3.9.6) the respective abdominal wall defect size was measured. RESULTS: The mean fascial defect size was 58.3 (SD 20.2) mm2. Bladed and bladeless trocars did not significant differ in terms of caused fascial defect size [bladed, 56.6 (SD 20) mm2 vs. bladeless, 59.5 (SD 20.6) mm2, p = 0.7]. Without significance the insertion of bladeless trocars led to the largest (Kii Fios™ First entry, APPLIEDMEDICAL©, 69.3 mm2) and smallest defect size (VersaOne™ (COVIDIEN©, 54.1 mm2). CONCLUSION: Bladed and bladeless conical 12-mm trocars do not differ in terms of caused fascial defect size in the Porcine Model at hand. The occurrence of a trocar site hernia might be largely independent from trocar design.

Trocar site hernia after gastric sleeve.

BACKGROUND: Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position was found to be a reliable method for the detection of TSH following gastric bypass (LRYGB). In the present study, our aim was to examine the incidence of TSH after gastric sleeve, and further to investigate the proportion of symptomatic trocar site hernias. METHODS: Seventy-nine patients subjected to laparoscopic gastric sleeve in 2011-2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey. RESULTS: The incidence of trocar site hernia was 17 out of 79 (21.5%), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no significant correlation between patient symptoms and a TSH. CONCLUSIONS: The incidence of TSH is high after laparoscopic gastric sleeve, a finding in line with several recent studies as well as with our first trial on trocar site hernia after LRYGB. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of a trocar site hernia can be serious, the proportion of symptomatic TSH needs to be more clarified.

401 consecutive minimally invasive distal pancreatectomies: lessons learned from 20 years of experience.

BACKGROUND: This study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres. METHODS: Patients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the "early" and "recent" phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years. RESULTS: The study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months. CONCLUSION: In the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review.

BACKGROUND: In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min. CASE PRESENTATION: A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence. CONCLUSIONS: The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Trocar site hernia after laparoscopy: Early recognition prevents catastrophic sequelae.

BACKGROUND: Trocar site hernia is a rare but potentially serious complication of laparoscopic surgery that may lead to bowel incarceration and strangulation. Prompt diagnosis by emergency physicians facilitates timely intervention that prevents bowel necrosis. We report a case of trocar site hernia presenting to the emergency department (ED) with abdominal pain that was correctly diagnosed and promptly managed. CASE REPORT: A 25-year-old woman, gravida 2, abortion 2, underwent outpatient surgery and laparoscopic removal of a ruptured right-sided tubal pregnancy without any intraoperative difficulties. However, 48 h later, she presented to the ED complaining of acute abdominal pain and nausea. Computed tomography revealed a loop of small bowel herniating through a 12-mm right lower quadrant trocar site defect in the fascia. She was taken back to the operating room, where the computed tomography findings were confirmed and the entrapped bowel was successfully reduced and the fascial defect repaired. The patient was discharged home feeling much improved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Trocar site hernia is a rare but potentially dangerous complication that can present with acute symptoms or be asymptomatic if late in onset. Intestinal necrosis begins as soon as 6 h after constriction of blood flow to entrapped bowel, so timely intervention is critically important. Therefore, trocar site hernias should be considered in patients presenting with abdominal complaints after laparoscopic surgery and included in the differential diagnosis of bowel obstruction.

Incidence and risk factors for umbilical trocar site hernia after laparoscopic TAPP repair. A single high-volume center experience.

BACKGROUND: Trocar site hernia (TSH) is often underestimated after minimally invasive surgery. Scarce information is available about the incidence of TSH in patients undergoing laparoscopic hernioplasty. We aimed to evaluate the incidence and risk factors of umbilical TSH after laparoscopic TAPP hernioplasty in patients with and without an associated umbilical hernia. METHODS: A retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic inguinal TAPP repair during 2013-2018 was performed. After TAPP repair, the umbilical fascia was closed either by a figure-of-eight stitch with absorbable suture (G1) or by umbilical hernioplasty if it was present (G2). Multivariate logistic regression analysis was used to determine the TSH risk factors. Comparative evaluation regarding demographics, and operative and postoperative variables was performed. RESULTS: A total of 535 laparoscopic TAPP repairs were included. There were 359 (67.1%) patients in G1 and 176 in G2 (32.9%). Surgical site infection was higher in G2 (G1: 0.6% vs G2: 5.7%, p = 0.001). Overall TSH rate was 3.9% after a mean follow-up of 20 (12-41) months. Performing a concomitant umbilical repair significantly increased the risk of umbilical TSH (G1: 2.2% vs G2: 7.4%, p = 0.004). TSH rates in G2 were similar in patients with simple suture or mesh repairs (p = 0.88). Rectus abdominis diastasis (OR 37.8, 95% CI:8.22-174.0, p < 0.001) and inguinal recurrence (OR 13.5, 95% CI:2.04-89.5, p = 0.007) were independent risk factors for TSH. CONCLUSION: Although trocar site hernia after laparoscopic TAPP repair has a low incidence, its risk is significantly increased in patients with a concomitant umbilical hernia repair, rectus abdominis diastasis, and/or inguinal recurrence.

Trocar-site incisional hernia after laparoscopic colorectal surgery: a significant problem? Incidence and risk factors from a single-center cohort.

BACKGROUND: Trocar-site incisional hernia (TSIH) after laparoscopic surgery has been scarcely studied. TSIH incidence and risk factors have never been properly studied for laparoscopic colorectal surgery. METHODS: A retrospective analytic study in a tertiary hospital was performed including patients who underwent elective laparoscopic colorectal surgery between 2014 and 2016. Clinical and radiological TSIH were analyzed. RESULTS: 272 patients with a mean age of 70.7 years were included. 205 (75.4%) underwent surgery for a malignant disease. The most common procedure was right colectomy (108 patients, 39.7%). After a mean follow-up of 30.8 months 64 (23.5%) patients developed a TSIH. However, only 7 out of 64 (10.9%) patients with a TSIH underwent incisional hernia repair. That means that 2.6% of all the patients underwent TSIH repair. 44 (68.8%) patients had TSIH in the umbilical Hasson trocar. In the multivariate analysis, the existence of an umbilical Hasson trocar orifice was the only statistically significant risk factor for TSIH development. CONCLUSIONS: Incidence of TSIH was high, although few patients underwent incisional hernia repair. Most TSIH were observed in the umbilical Hasson trocar, which was the only risk factor for TSIH development in the multivariate analysis. Efforts should be addressed to avoid TSIH in the umbilical Hasson trocar.

Does closure of fascia, type, and location of trocar influence occurrence of port site hernias? A literature review.

BACKGROUND: Since the introduction of laparoscopic surgery, it has become more popular with many advantages over open surgery including faster recovery, shorter hospital stays, and decreased tissue trauma. Despite its benefits, laparoscopic surgery can result in its own unique complications, such as the formation of a trocar site hernia (TSH), which have been reported in approximately 0-1.0% of laparoscopic cases when using non-bladed trocars. METHODS: A literature review was performed from June 1990 to June 2019. PubMed was searched using the keywords "laparoscopic surgery," "trocar site hernia," and "port site hernia." Only articles in English were identified but not limited to the USA. RESULTS: The total number of patients in all articles was 18,533 with a mean follow-up period of 22.50 ± 1.76 months. The overall trocar site hernia rate was 0.104%. When comparing open vs. closed ports, there was no significant difference in the hernia incidence rate for 5-mm and 10-mm ports. When comparing bladed versus non-bladed trocars left open, there was a statistically significant difference with lower hernia incidence rates for non-bladed trocars over bladed trocars for 5-mm, 10-mm, and 12-mm ports. And when comparing trocar location from midline versus off-midline, there was a statistically significant higher TSH incidence in midline trocar locations. CONCLUSION: Results suggest that TSH rate is lower when using non-bladed trocars for any size of trocar. When comparing whether fascial closure had an effect, the 5-mm and 10-mm ports had no difference in incidence rates and leaving the fascia open can reduce operative time, risk of needlestick injuries, and overall procedural cost. In addition, trocars at midline locations resulted in higher TSH incidence rates. Future research is still needed to assess for other factors that may influence hernia formation and how it can be minimized.

Laparoscopic-assisted Stamm-gastrostomy: technical modifications to ease suturing inside the minimal trocar site.

Laparoscopic gastrostomy tube placement has been increasingly adopted by pediatric surgeons. We herein report our experience with the performance of a laparoscopic-assisted Stamm-operation inside the minimal trocar site without the extension of the trocar site incision or mini-laparotomy. We present some technical modifications that facilitate suturing inside the minimal trocar site. METHODS: A retrospective chart review was conducted of cases involving patients who underwent laparoscopic-assisted gastrostomy, using a simple extracorporeal method inside the trocar site from April 1998 to March 2018. RESULTS: One hundred five gastrostomy tubes were placed in a laparoscopic-assisted operation. All but two of the cases involved patients with neurological impairment. The mean age was 12.5 years; 28 cases were > 16 years of age. Seventy-five cases underwent gastrostomy during laparoscopic fundoplication. All gastrostomy procedures were completed without intraoperative difficulties; however, 8 cases, which involved a thick abdominal wall, required extension of the trocar site. No cases required conversion to open gastrostomy. No major complications were observed. Two patients developed continuous peristomal cellulitis after surgery, due to the mismatch of the site position and an unsuitable button device size. CONCLUSION: We demonstrated that laparoscopic gastrostomy with fully extracorporeal suturing within the trocar site is feasible and beneficial, especially for the most neurologically impaired pediatric cases. Technical modification, changing the order of the process, and suturing technique in the minimal space, made it easier to perform the procedures inside the minimal trocar hole.

Incidence and risk factors for trocar-site incisional hernia detected by clinical and ultrasound examination: a prospective observational study.

BACKGROUND: Trocar site incisional hernia (TSIH) is the most frequent complication associated with laparoscopic surgery. Few studies currently describe its incidence or risk factors. The aim of this report is to determine the real incidence of TSIH and to identify risk factors. METHODS: A cross-sectional prospective study was performed including consecutive patients who underwent a laparoscopic procedure during a 4 months period. All the patients were assessed both clinically (TSIHc) and by an ultrasonographic examination (TSIHu). The main variable studied was the incidence of TSIH. A multivariate analysis was performed to identify risk factors. RESULTS: 76 patients were included. 27.6% of patients were clinically diagnosed as having TSIH (TSIHc) but only 23.7% of those cases were radiologically confirmed (TSIHu). In the logistic regression analysis, age > 70 years (OR 3.462 CI 1.14-10.515, p = 0.028) and body mass index (BMI) ≥ 30 kg/m2 (OR 3.313 CI 1.037-10.588, p = 0.043) were identified as risk factors for TSIH. The size of the trocar also showed statistically significant differences (p < 0.001). Mean follow-up time was 34 months. CONCLUSIONS: TSIH is under-diagnosed due to the lack of related symptomatology and the inadequacy of the postoperative follow-up period. We detected discrepancies between the clinical and ultrasonographic examinations. TSIHu should be considered as the gold standard for the diagnosis of TSIH. Risk factors such as age, BMI and size of the trocar were confirmed. Patients should be followed-up for a minimum of 2 years. Trial registration The study has been retrospectively registered in Clinicaltrials.gov on June 4, 2020 under registration number: NCT04410744.

Single-incision surgery trocar-site hernia: an updated systematic review meta-analysis with trial sequential analysis by the Minimally Invasive Surgery Synthesis of Interventions Outcomes Network (MISSION).

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a new technique that aims to minimize abdominal wall trauma and improve cosmesis. Concerns have been raised about the risk of trocar-site hernia following SILS. This study aims to assess the risk of trocar-site hernia following SILS compared to conventional laparoscopic surgery, and investigate whether current evidence is conclusive. METHODS: We performed a systematic search of MEDLINE, AMED, CINAHL, CENTRAL, and OpenGrey. We considered randomized clinical trials comparing the risk of trocar-site hernia with SILS and conventional laparoscopic surgery. Pooled odds ratios with 95% confidence intervals (CI) were calculated using the Mantel-Haenszel method. Trial sequential analysis using the Land and DeMets method was performed to assess the possibility of type I error and compute the information size. RESULTS: Twenty-three articles reporting a total of 2471 patients were included. SILS was associated with higher odds of trocar-site hernia compared to conventional laparoscopic surgery (odds ratio 2.37, 95% CI 1.25-4.50, p = 0.008). There was no evidence of between-study heterogeneity or small-study effects. The information size was calculated at 1687 patients and the Z-curve crossed the O'Brien-Fleming α-spending boundaries at 1137 patients, suggesting that the evidence of higher risk of trocar-site hernia with SILS compared to conventional laparoscopic surgery can be considered conclusive. CONCLUSIONS: Single-incision laparoscopic procedures through the umbilicus are associated with a higher risk of trocar-site hernia compared to conventional laparoscopic surgery.

Trocar site hernia development in patients undergoing robotically assisted or standard laparoscopic staging surgery for endometrial cancer.

OBJECTIVES: To compare the incidence and potential risk factors of trocar site hernia formation in women undergoing robotically assisted versus standard laparoscopic staging (RBT vs. LSC, respectively) for endometrial cancer. METHODS: We retrospectively identified all patients who underwent MIS staging for endometrial cancer at our institution from 01/09-12/12. Data collection involved the review of all operative notes, postoperative follow-up visit notes, and postoperative imaging reports. Appropriate statistical tests were used. RESULTS: We identified 760 eligible patients (LSC, 193; RBT, 567). The overall median age was 61years (range, 33-90). The median BMI was 28.5kg/m2 for LSC (range, 16.6-67.6) and 29.5kg/m2 for RBT (range, 17.9-66) patients (p=0.8). A trocar site hernia developed in 16 patients (2.1%)-5 (2.6%) of 193 LSC and 11 (1.9%) of 567 RBT patients (p=0.6). Median time to hernia diagnosis was 13months (range, 5-20.5) and 18months (range, 3-49), respectively (p=0.5). All hernias in the LSC cohort developed at the camera trocar site. In the RBT cohort, 10 developed at the camera trocar site and 1 at a lateral trocar site. Only BMI was associated with the development of hernias. A hernia was diagnosed in 7 (6.9%) of 101 patients with a BMI ≥40kg/m2 compared with 9 (1.4%) of 659 with a BMI <40kg/m2 (p=0.001). CONCLUSION: MIS for endometrial cancer is associated with a low rate of trocar site hernia formation, with similar rates associated with RBT and standard LSC. Higher BMI is associated with the development of postoperative trocar site hernias.

Effect of bag extraction to prevent wound infection on umbilical port site wound on elective laparoscopic cholecystectomy: a prospective randomised clinical trial.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard treatment for gallbladder stones. Complications due to laparoscopic procedure are rare, but rate of wound infection in some studies is about 8 %. From January 2007 to December 2008, 320 laparoscopic cholecystectomies were performed at our hospital, and in 4.7 % of them, wound infection of the umbilical trocar was identified. We believe that this infection rate could be lower and that it is necessary to implement a new technique to reduce the wound infection. The aim of the study was to evaluate the benefits of bag extraction of gallbladder to prevent the wound infection. METHODS: Two-arm, parallel, 1:1, randomised controlled trial (ISRCTN38095251). All patients suffering from symptomatic gallbladder stones of low risk were enrolled for this study and were divided into two groups in basics gallbladder extraction: with (80 patients) or, as usually, without bag (76 patients). All patients with cholecystitis or accidental gallbladder perforation were excluded. We compared all the results to establish whether meaningful differences were found. RESULTS: The final sample analysed (156 patients) consisted of 121 women and 35 men; there were 80 in the control group and 76 in the study group. There were 15 (9.6 %) diagnosed wound infections, eight cases in the study group and seven in the control group. There were no statistically significant differences. CONCLUSIONS: The determinant of wound infection in elective laparoscopic cholecystectomy is not the direct contact of the gallbladder with the wound; therefore, bag extraction is not necessary.

Herniation formation in women undergoing robotically assisted laparoscopy or laparotomy for endometrial cancer.

OBJECTIVE: To compare the incidence of trocar site hernia in women who underwent robotically assisted laparoscopic surgery (RBT) for endometrial cancer staging with the incidence of ventral hernia formation in patients who underwent laparotomy (LAP) for the same indication. To analyze risk factors for hernia formation in women undergoing RBT for endometrial cancer. METHODS: We retrospectively identified all patients who underwent surgical staging for endometrial cancer via RBT or LAP from 2009-2012. Clinicopathologic data were analyzed. Appropriate statistical tests were used. RESULTS: 738 patients were staged via RBT (n=567) or LAP (n=171). Overall median age was 61 years (RBT range, 33-90; LAP range,28-86; p=0.4). Median BMI was 29.5 kg/m(2) (range, 17.9-66) and 30.3 kg/m(2) (range, 16.8-67.2), respectively (p=1.0). Eleven (1.9%) of 567 patients in the RBT cohort developed a trocar site hernia compared with 11 (6.4%) of 171 LAP patients who developed a ventral hernia (p=0.002). Median time to diagnosis was 18 months (range, 3-49) and 17 months (range, 7-30), respectively (p=0.7). Of the 11 RBT patients who developed a trocar site hernia, 10 (91%) were midline defects and 1 (9%) was a lateral defect of a prior inferior epigastric port site. No hernias required emergent operative intervention. Four (0.7%) of 567 RBT patients compared with 2 (1.2%) of 171 LAP patients required surgical hernia repair (p=0.4). CONCLUSIONS: Trocar site herniation after RBT staging for endometrial cancer is uncommon and less likely to occur than ventral hernia formation with LAP staging. Furthermore, surgical revision rates are low.

Incisional and port-site hernias following robotic colorectal surgery.

BACKGROUND: The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. MATERIALS AND METHODS: A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. RESULTS: The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8 %) with a mean follow-up of 16.5 months. The overall incisional hernia rate was 5.8 %. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68 %, p < 0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. CONCLUSION: Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

5-millimeter Trocar-site Hernias After Laparoscopy Requiring Surgical Repair.

Trocar-site hernias are rare complications of laparoscopic surgery. Although trocar-site hernias occur more often at >10-mm sites, hernias can still develop at 5-mm sites after laparoscopy and can lead to serious complications. The primary objective of this review is to summarize the current medical literature pertaining to the clinical presentation and predisposing risk factors of trocar-site hernias at 5-mm sites after laparoscopy. A total of 295 publications were identified, 17 (5.76%) of which met the inclusion criteria. Twenty-seven patients with trocar-site hernias were identified after laparoscopic cases. The median age (interquartile range) for all adult patients with trocar-site hernias was 63 years (interquartile range, 39.5-66.5 years). Eight of the 18 patients (44.4%) undergoing gynecologic laparoscopy were parous although details of parity were not reported in most publications. Simple manual reduction or laparoscopic reduction with fascial closure (21 patients [84%]) was used more often compared with exploratory laparotomy (4 patients [16%], p < .001) to manage trocar-site hernias. There was no statistical difference in the location of trocar-site hernias (i.e., umbilical [14 patients, 56%] vs nonumbilical/lateral [11 patients, 44%], p = .12). Findings of this review suggest that increased operative times and excessive manipulation can extend 5-mm fascial incisions, thereby increasing the risk of trocar-site hernias. Parous women older than 60 years may have unrecognized fascial defects, which confer a higher risk of trocar-site hernias after laparoscopic surgery, even in the absence of incision manipulation or prolonged surgical duration. Such patients may benefit from closure of 5-mm fascial incisions although prospective data are required to validate the overall generalizability of this management strategy.

Trocar-site Herniation after Laparoscopic Myomectomy via Culdotomy Extraction.

Trocar-site hernia is a rare and life-threatening complication of laparoscopic abdominal surgery; 5-mm trocar-site bowel herniation is rarer than ≥ 10-mm trocar-site herniation. We present a 41-year-old female patient on the postoperative 6th day with laparoscopic myomectomy admitted to our emergency department with severe vomiting and nausea. At the end of the evaluations, she was diagnosed with 5-mm trocar-site small bowel herniation. A herniated small bowel segment was rescued through the laparotomy. After full recovery, the patient was discharged on the 3rd day of hospitalization. Although there is no consensus on the closure of small fascia incisions (<10 mm) routinely, we suggest that all fascia incisions should be assessed in patients at risk to prevent trocar-site hernias. According to our investigation for trocar-site hernia in the literature, laparoscopic myomectomy may be considered a risk factor.