Abstract
Purpose
Single-incision laparoscopic surgery (SILS) has been demonstrated to be a feasible alternative to multiport laparoscopy, but concerns over port-site incisional hernias have not been well addressed. A retrospective study was performed to determine the rate of port-site hernias as well as influencing risk factors for developing this complication.
Methods
A review of all consecutive patients who underwent SILS over 4 years was conducted using electronic medical records in a multi-specialty integrated healthcare system. Statistical evaluation included descriptive analysis of demographics in addition to bivariate and multivariate analyses of potential risk factors, which were age, gender, BMI, procedure, existing insertion-site hernia, wound infection, tobacco use, steroid use, and diabetes.
Results
787 patients who underwent SILS without conversion to open were reviewed. There were 454 cholecystectomies, 189 appendectomies, 72 colectomies, 21 fundoplications, 15 transabdominal inguinal herniorrhaphies, and 36 other surgeries. Cases included 532 (67.6 %) women, and among all patients mean age was 44.65 (±19.05) years and mean BMI of 28.04 (±6). Of these, 50 (6.35 %) patients were documented as developing port-site incisional hernias by a health care provider or by incidental imaging. Of the risk factors analyzed, insertion-site hernia, age, and BMI were significant. Multivariate analysis indicated that both preexisting hernia and BMI were significant risk factors (p value = 0.00212; p value = 0.0307). Morbidly obese patients had the highest incidence of incisional hernias at 18.18 % (p value = 0.02).
Conclusions
When selecting patients for SILS, surgeons should consider the presence of an umbilical hernia, increased age and obesity as risk factors for developing a port-site hernia.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
With the adoption of laparoscopic surgery over the past few decades, investigators have attempted to categorize and risk stratify the complication of trocar site hernia. Reports in the literature regarding rates of these hernias are conflicting, and many risk factors have been suggested. Early studies had established umbilical hernia rates as low as 1.5 % for laparoscopic cholecystectomy when using the Hasson technique [1]. A more recent prospective study by Comajuncosas et al. [2], however, reports a rate of 25.9 % when following patients regularly for 3 years with physical exam and ultrasound. Elevated BMI, pre-existing umbilical hernia, wound infection, age, and gender have all been proposed as risk factors for developing such a complication with the traditional laparoscopic approach [3–5]. Questions remain regarding optimal closure technique in the setting of multiple patient risk factors, and these concerns have been complicated by the use of larger laparoscopic incisions for insertion of multi-trocar ports.
In recent years, single-incision laparoscopic surgery (SILS) has been demonstrated to be a safe alternative to multiport laparoscopy for many laparoscopic procedures, but despite its cosmetic appeal, concerns remain due to loss of triangulation, increased costs, and lack of randomized trials proving objective benefit to patients [6–9]. Furthermore, studies analyzing long-term complications such as port-site incisional hernia have been few. Agaba et al. [10] recently reported single-incision port-site hernia incidence of 2.9 % in 205 patients that were followed prospectively 30–36 months after cholecystectomy; 50 % of these complications were in morbidly obese patients. In contrast, Marks et al. [11] published a much higher incisional hernia rate of 8.4 % in a 1 year randomized controlled trial comparing SILS and traditional multiport cholecystectomy, suggesting that significantly higher hernia rates may outweigh the potential cosmetic benefit. Studies intended to analyze specific risk factors for incisional hernia after SILS have not been published. Such analysis may help direct physicians in choosing ideal patients for the single-incision approach to minimize future complications. A retrospective review of patients who underwent any SILS procedure at our facility was conducted to determine the rate of port-site incisional hernias as well as influencing risk factors for developing this complication.
Materials and methods
Patient selection
All single-incision laparoscopic surgeries performed at a single institution by three surgeons in our integrated multi-specialty healthcare system between November 2008 and December 2012 were reviewed via a comprehensive electronic medical record system. This time period included the initial experience with SILS and the development period of a consistent closure technique. The decision to perform SILS was made according to surgeon preference as the time period includes the initial learning curve for the technique; no surgeon had experience with SILS prior to the study. Patient demographics recorded included age, gender, and BMI. Additional information gathered included existing insertion site hernia, current tobacco use, daily steroid use, and diabetes status. Intra-operatively, conversions from SILS to multiport, hand-assisted laparoscopy, and laparotomy were documented. For the purpose of analyzing risk factors for incisional hernia after SILS surgery, surgeries in which the port-site was extended for hand-assist or open conversion were not included. Totally extraperitoneal herniorrhaphies were also excluded. Recurrence, incarceration, and strangulation were documented for incisional hernias that were discovered.
Surgical method
For a typical SILS case in our institution, access is gained to the peritoneal cavity with a 2 cm incision within the umbilicus and extending to the fascia. A three-trocar SILS™ (Covidien, Mansfield, MA) port is inserted through the fascial defect using a Kelly clamp. Instrumentation includes a 5 mm bariatric 30° angled scope with right angle adapter and standard 5 mm non-articulating instruments. After completion of the laparoscopic procedure, the SILS port is removed and the fascial defect is closed using 0 polyglycolic acid suture in two figure-of-eights. The soft tissues are loosely approximated using 3–0 polyglycolic acid suture. In lieu of closing the skin with a 4–0 monofilament suture, a suction dressing is created by applying a small amount of triple antibiotic ointment, gauze, and a clear adhesive bandage, after which air is suctioned out using a 60 cc syringe and 27 gauge needle [12]. For colectomies, often the incision was extended to 3 cm to allow for extraction of the specimen, necessitating a different closure technique; in these cases the fascia was closed using a number 1 looped absorbable monofilament suture in a running fashion.
Statistical analysis
All variables are described using means (standard deviations) or percentages, as appropriate. Statistical evaluation included descriptive analysis of demographics in addition to bivariate analysis of potential risk factors, which included age, gender, BMI, procedure, existing insertion-site hernia, wound infection, tobacco use, steroid use, and diabetes. Bivariate analysis consists of either t-tests or Chi-squared/Fisher’s exact tests, as appropriate, comparing those with and without complication. Performing a multivariate analysis allowed for statistical analysis of each outcome variable while accounting for more than one covariate at a time. In this portion of the analysis, logistic regression models were built for incisional hernia complication, including as covariates surgical procedure and any potential risk factor reaching a significance level of 0.2 on the bivariate analyses above. Finally, to discern which category of obesity was at highest risk, we performed an additional analysis, comparing hernia rates in patients with BMI less than 25, greater than 25–30, greater than 30–35, greater than 35–40, and greater than 40, using Chi-squared tests.
Results
Upon review, 787 SILS cases met inclusion criteria for this study. There were 454 cholecystectomies, 189 appendectomies, 72 colectomies, 21 fundoplications, 15 transabdominal inguinal herniorrhaphies, and 36 procedures classified as other. Cases included 532 (67.6 %) women, and overall patients had a mean age of 44.65 (19.05) (range 5–91) years and a mean BMI of 28.04 (6) (range 13.3–49.5). Of these patients, 50 (6.35 %) patients were documented as developing a port-site incisional hernia by physical exam or by incidental imaging, for which they chose to follow up with a provider. Bivariate analysis revealed that of the potential risk factors investigated, only pre-existing insertion site hernia, age, and BMI were significant (Table 1). Patients with pre-existing trocar site hernias had an incisional hernia rate of 12.64 %. Patients with a BMI greater than or equal to 40 had the highest rate of incisional hernia at 18.18 % (Table 2, p value = 0.02). Of note, surgical procedure type was not a statistically significant factor for incisional hernia (Tables 1, 3). Additionally, the overall wound infection rate was 2.03 % and was not found to be a statistically significant influencing factor for developing a hernia in this analysis (Table 1).
Multivariate analysis using covariates age, BMI, insertion site hernia, and diabetes indicated that both a preexisting hernia and BMI were significant independent risk factors (Table 1). Of the incisional hernias that developed, 18 patients (36 %) had a prior umbilical incision, and 9 (18 %) were classified as recurrent incisional hernias. There were no incarcerated or strangulated hernias. Of the 50 hernias detected, 30 required non-emergent surgical intervention due to symptomatic presentation. Average time to presentation in our facility was 9.41 months. Average follow up was 34 months and ranged from 12 to 62 months.
Discussion
The goal of this review was to provide direction to surgeons considering the single-incision technique by denoting potential risk factors for incisional hernia. Our experience indicates a rate of clinically significant incisional hernias of 6.35 %. This rate is higher for the morbidly obese, elderly, and patients with pre-existing hernias. The overall number falls within the broad range reported for incisional hernias when using the Hasson trocar, which varies from 1.5 to 25 %, but is considerably higher than that reported in the study by Agaba et al. [10] for SILS cholecystectomy. This disparity may be due to difference in closure technique, larger database, longer maximum follow up, or a wider variety of cases, though surgical procedure itself was not a significant influencing factor in this analysis. Descriptions of closure for single-incision port sites in the literature are varied, including interrupted, two or three figure-of-eights, and running fashions, as well as both absorbable and non-absorbable suture [10, 13, 14]. Communication between high-volume SILS centers and standardization of closure technique may be valuable in reducing these rates.
Supporters of SILS cite its cosmetic appeal, patient satisfaction, and potentially reduced post-operative pain with decreased number of incisions [6, 7, 11, 15, 16]. Other advantages such as shorter length of stay for colectomy and decreased risk of trocar morbidity for inguinal herniorrhaphy have also been suggested [17–20]. Skeptics argue a potentially substantial learning curve and unnecessary expenses with the use of specialized ports and articulating instruments [8, 9, 21]. We have argued that increased experience and standardization of training and technique may be useful in overcoming these difficulties, and with most procedures, we find that standard laparoscopic instruments can be utilized [21, 22]. Robotic single-incision has been introduced as a potential way to overcome triangulation and clashing difficulties, but hospital expense and lengthy operative times remain serious concerns [23–25].
Aside from cholecystectomy, few randomized trials are available regarding SILS and most lack long term follow up specific to incisional hernia rates. This review represents one of the largest databases of single-incision surgery within a single institution and offers a unique opportunity to learn from our collective experience. The use of a bariatric camera with 90° angled adapter, for example, minimizes crowding at the port. Closure of the umbilical skin with only deep dermal interrupted stitches and a homemade suction dressing has also decreased post-operative pain at the umbilicus.
In our study we found the highest incisional hernia rates in patients who were morbidly obese and in those with pre-existing umbilical hernias. Agaba et al. also demonstrated higher incidence in this population, with 83 % of patients who developed incisional hernias classified as obese and 50 % of these patients meeting criteria for morbid obesity [10]. Our practice now avoids performing SILS in the obese due to increased operative difficulty and high incisional hernia rates, which could be explained by increased visceral fat and subsequent increase in intra-abdominal pressure at the umbilicus. In addition, surgeons may wish to consider alternative closing techniques, such as three figure-of-eights utilized by Agaba et al. who had a comparatively lower incisional hernia rate overall. Closure of umbilical hernias encountered during laparoscopic cholecystectomy with interrupted non-absorbable suture has been suggested in the literature [5]. The use of mesh in clean-contaminated cases has also been identified as a potential method of decreasing port-site hernias in high risk patients who may not have a pre-existing hernia [26].
Limitations of this study include its retrospective design as well as inherent bias in surgeon selection of approach. Universal electronic medical records across a multi-specialty healthcare system facilitated reporting of complication even several years after surgery, but some complications may have been missed due to loss to follow up in our system. Additionally, routine imaging was not performed in diagnosing hernias. Thus, the reported rate may be lower than the actual rate, but we believe those documented to be clinically relevant as they involved utilization of healthcare resources, follow up or surgery after discovery. A prospectively designed study comparing SILS and multiport approaches may provide more accurate hernia rates but could be difficult to maintain without significant resources.
SILS is safe and feasible, but large reviews and randomized controlled trials regarding long term complications are limited. This large retrospective review holds important clinical implications for surgeons and their patients, who may be able to balance a desire for improved cosmetic result with patient-specific risk of long-term complication.
References
Mayol J, Garcia-Aguilar J, Ortiz-Oshiro E et al (1997) Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion. World J Surg 21:529–533
Comajuncosas J, Hermoso J, Gris P et al (2014) Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study. Am J Surg 207:1–6
Uslu HY, Erkek AB, Cakmak A et al (2007) Trocar site hernia after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech 17:600–603
Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M (2004) Trocar site hernia. Arch Surg 139:1248–1256
Azurin DJ, Go LS, Arroyo LR, Kirkland ML (1995) Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia. Am Surg 61:718–720
Markar SR, Karthikesalingam A, Thrumurthy S et al (2012) Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis. Surg Endosc 26:1205–1213
Bucher P, Pugin F, Buchs NC et al (2011) Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy. Br J Surg 98:1695–1702
Pucher PH, Sodergren MH, Singh P et al (2013) Have we learned from lessons of the past? A systematic review of training for single incision laparoscopic surgery. Surg Endosc 27:1478–1484
Greaves N, Nicholson J (2011) Single incision laparoscopic surgery in general surgery: a review. Ann R Coll Surg Engl 93:437–440
Agaba E, Rainville H, Ikedilo O, Vemulapali P (2014) Incidence of port-site incisional hernia after single-incision laparoscopic surgery. JSLS 18:204–210
Marks J, Phillips M, Tacchino R et al (2013) Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 216:1037–1047
Muensterer OJ, Keijzer R (2011) A simple vacuum dressing reduces the wound infection rate of single-incision pediatric endosurgical appendectomy. JSLS 15:147–150
Krajinovic K, Ickrath P, Germer CT, Reibetanz J (2011) Trocar-site hernia after single-port cholecystectomy: not an exceptional complication? J Laparoendosc Adv Surg Tech 21:919–921
Scheib SA, Fader AN (2014) Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique. Am J Obstet Gynecol 212(2):179.e1–179.e179
Champagne BJ, Papaconstantinou HT, Parmar SS et al (2012) Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg 255:66–69
Ma J, Cassera MA, Spaun GO, Hammill CW, Hansen PD, Aliabadi-Wahle S (2011) Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 254:22–27
Papaconstantinou HT, Sharp N, Thomas JS (2011) Single-incision laparoscopic right colectomy: a case-matched comparison with standard laparoscopic and hand-assisted laparoscopic techniques. J Am Coll Surg 213:72–80
Gandhi DP, Ragupathi M, Patel CB et al (2010) Single-incision versus hand-assisted laparoscopic colectomy: a case matched series. J Gastrointest Surg 14:1875–1880
Tran H (2011) Safety and efficacy of single incision laparoscopic surgery for total extraperitoneal inguinal hernia repair. JSLS 15:47–52
Buckley FP, Vassaur H, Monsivais S et al (2014) Comparison of outcomes for single-incision laparoscopic inguinal herniorrhaphy and traditional three-port laparoscopic herniorrhaphy at a single institution. Surg Endosc 28:30–35
Carter JT, Kaplan JA, Nguyen JN et al (2014) A prospective, randomized controlled trial of single-incision laparoscopic vs conventional laparoscopic appendectomy for treatment of acute appendicitis. J Am Coll Surg 218:950–959
Buckley FP, Vassaur H, Monsivais S et al (2014) Single-incision laparoscopic appendectomy versus traditional three-port laparoscopic appendectomy: an analysis of outcomes at a single institution. Surg Endosc 28:626–630
Gonzales AM, Rabaza JR, Donkor C et al (2013) Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms. Surg Endosc 27:4524–4531
Pietrabissa A, Sbrana F, Morelli L et al (2012) Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology. Arch Surg 147:709–714
Ross SB, Sawangkum P, de La Vega KA et al (2013) Single-site robotic cholecystectomy (SSRC): an initial review of safety and feasibility. Miner Chir 68:435–443
Armañanzas L, Ruiz-Tovar J, Arroyo A et al (2014) Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia. A randomized clinical trial. J Am Coll Surg 218:960–968
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
F.P. Buckley, MD has received a speaker honorarium in the past from Medronic. No other authors have any conflicts.
Ethical approval
All procedures performed were in accordance with the ethical standards of the institution, received IRB approval, and with the 1964 Helsinki declaration and its later amendments.
Informed consent
As a retrospective study, formal consent was not obtained from the patients and was not required.
Funding
This study had no external funding.
Rights and permissions
About this article
Cite this article
Buckley, F.P., Vassaur, H.E., Jupiter, D.C. et al. Influencing factors for port-site hernias after single-incision laparoscopy. Hernia 20, 729–733 (2016). https://doi.org/10.1007/s10029-016-1512-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10029-016-1512-8