Fascial closure helps prevent port-site hernias

Shanghai, China-Fascial closure is an effective method to prevent port-site hernias, even when non-bladed trocars are used, according to a study presented at the World Congress of Endourology & SWL.

Bladed trocars and midline wounds from trocars >5 mm have a higher incidence of herniation; therefore, most laparoscopic surgeons avoid bladed trocars and will close 10/12-mm midline port sites. Although the incidence of hernias is very low in lateral port sites, some advocate closing these as well.

"Incidence per trocar site is not a valid assessment; incidence per patient is more important," said lead author Thomas Hsu, MD, director of laparoscopic and robotic surgery at Kaiser Permanente Santa Clara Medical Center, Palo Alto, CA.

The purpose of the study was to compare the incidence of port-site hernias in closed and non-closed trocar sites to measure the fascial defect created by standard trocars and to prospectively evaluate the efficacy of the Carter-Thomason CloseSure XL device (Inlet Medical, Inc., Eden Prairie, MN).

Non-midline port sites were left unclosed in 95 patients, while 78 patients had all port sites closed with the help of a Carter-Thomason device. The incidence of port-site hernias requiring re-operation in unclosed patients was 6.3%, the majority of which were 10/12-mm ports lateral to the umbilicus. One patient in the closed group experienced a subclinical hernia, which was managed conservatively.

Prior to wound closure, the diameter of the fascial defects of 100 10/12-mm port sites was measured with Hegar dilators. The average width was 15 mm, and there was a correlation between larger fascial defects and longer operative times. Dr. Hsu speculated that hernias might result from pressure secondary to abdominal strain that separates the unclosed fascial edges to their maximum diameter.

All trocars were of a non-bladed, dilating design.

In the last 20 port sites closed with the Carter-Thomason device, close visual inspection revealed incomplete fascial closure in 55%, with either one or neither fascial edge included in the closure.

Dr. Hsu recommended closing all trocar wounds ≥10 mm, even non-midline incisions made with dilating as opposed to bladed trocars. He further reiterated the importance of accurate reporting of hernia incidence.

"You don't take a trocar site back to the operating room; you take the whole patient," Dr. Hsu said.