Trocar-Site Hernia After Single-Port Cholecystectomy: Not an Exceptional Complication?

Introduction

In recent years, single-port surgery (SPS) has emerged as a seminal advancement in minimally invasive surgery of the biliary tract and is, for selected patients, a viable alternative to the standard multiport laparoscopy.^1–4 A multitude of articles now document the safety and feasibility of this procedure and the most apparent advantage is the excellent cosmesis. ⁵ However, it is still too early to assess true benefits from SPS as reports of larger series are just yet beginning to emerge.

Beside, there is still a lack of high-evidence data regarding risk factors for trocar-site hernia (TSH) even after conventional laparoscopic surgery. ⁶ When compared with standard multiport laparoscopy, the larger fascial incision in SPS (or multiple fascial incisions located close to each other) may imply a potentially increased risk of surgical-site complications, such as herniation. Although a recent review reported that the rate of TSH after single-port cholecystectomy is exceedingly low, ⁷ this is, of course, biased by a short and incomplete follow-up of the most included series. Consequently, the long-term risk of access-site complications in SPS is still unpredictable.

We herein report the results of a structured follow-up including a meticulous clinical examination and ultrasonography of the access site in 50 patients 17 months (median) after single-port cholecystectomy with the X-Cone Single-Port Laparoscopic Device (X-Cone™; KARL STORZ GmbH, Tuttlingen, Germany).

Patients and Methods

Since July 2009, patients who underwent single-port cholecystectomy at our university teaching hospital were eligible for inclusion in the current study. Indication for initial surgery was symptomatic cholelithiasis, including seven cases of acute cholecystitis. Preoperatively, diagnosis of gallstones was documented by ultrasonography in all cases and there were no signs of cholestasis in any case. All surgeries were performed by a single surgeon (K.K.) using a completely reusable single-port access device (X-Cone) in a technique that has recently been described. ⁸

The fascial defect at the umbilicus was closed using interrupted absorbable sutures (Vicryl 1 [or PDS 1]; Ethicon GmbH, Norderstedt, Germany) and the skin incision was closed with a 4-0 absorbable subcuticular running suture.

The primary outcome parameter for this study was access-related midterm morbidity, and all patients, at follow-up visit, underwent a thorough physical examination as well as examination of the umbilical access site with ultrasonography (EnVisor; Philips Medical Systems, Bothell, Washington), to detect even subclinical TSH.

Results

Between July 2009 and May 2011, n=78 patients (n=54 females), with a median age of 42 years (range: 18–85 years), underwent single-port cholecystectomy. The median body mass index (BMI) was 25.4 kg/m² (range: 17–39 kg/m²).

Until May 2011, the first 50 patients (n=32 females) attended a follow-up examination (clinical examination and ultrasonography of the access site) at a median follow-up time of 17 months (range: 9–23 months), and were included in the current study. The median age of these patients was 43 years (range: 19–84 years) and the median BMI was 26 kg/m² (range: 18–39 kg/m²). Fourteen of the 50 patients (28%) had a history of previous abdominal surgery (appendectomy: n=6; Cesarean section: n=2; bariatric surgery: n=2; hysterectomy: n=1; prostatectomy: n=1; vascular surgery: n=2). Initial single-port cholecystectomy (median operative time: 88 minutes; range: 42–156 minutes) was carried out for symptomatic cholelithiasis and for acute cholecystitis in 43 and 7 cases, respectively, and was successfully managed without additional trocar placement or conversion to open technique in all but one case. In one patient, an additional 5-mm trocar was placed subcostally to manage a bleeding from the liver bed. This conversion did not result in further complications.

We recorded postoperative complications in 5 of the 50 patients (10%) after single-port cholecystectomy (Table 1). Of these, 4 occurred in the early postoperative course and presented as mild wound complications. In 2 of these patients, the wound was (bedside) partially reopened, and in the remaining cases, the wound situation required no specific treatment. No patient suffered from long-term sequale. Of note, no biliary complications (bile leakage, retained stones, etc.) were recorded.

One of the 50 patients (2%) experienced a symptomatic TSH 4 months after surgery. She was a normal-weight, 62-year-old female patient (sports teacher) with no significant comorbidity (American Society of Anesthesiologists [ASA] II). She underwent single-port cholecystectomy in August 2010. Initially she was diagnosed as having choledocholithiasis and was treated by endoscopic retrograde cholangiopancreaticography (ERCP) 5 days prior to surgery. The perioperative course was uneventful without signs of wound complication, and she was discharged on the second postoperative day (POD). However, in November 2010, a 20-mm reducible, symptomatic incisional hernia at the umbilicus was clinically diagnosed and confirmed by ultrasonography (Fig. 1). In April 2011, she underwent subsequent tension-free hernia repair using a nonresorbable sublay mesh. She was discharged on POD 3 and, until now, is of good convalescence.

OPEN IN VIEWER

FIG. 1.

Ultrasound picture of a trocar-site hernia at the umbilicus in a 62-year-old female 4 months after initial surgery.

Discussion

By means of a structured follow-up examination in 50 patients 17 months after single-port cholecystectomy, we found that the rate of TSH was 2%, which largely resembles the rate of TSH after standard multiport laparoscopy (0.5–2%). ⁹ Further, all included patients underwent detailed follow-up examination (clinically and with ultrasonography of the access site) at a median time of 17 months postoperatively. In the current series, both the operative setting and the follow-up visit were highly standardized. All surgeries were performed by a single surgeon (K.K.) using only one access device (X-Cone), and fascial closure technique was comparable in all patients, although we changed the suture material after the first case of TSH using a slow absorbable suture since then.

Following the current literature, incisional hernia after single-port cholecystectomy seems exceptional, ⁷ although the (increased) tissue trauma related to a larger fascial incision and a probably increased manipulation at the port site does not comply with this observation. However, these reports still represent very early results, and it is reasonable that the true incidence of TSH after single-port cholecystectomy is currently markedly underestimated for several reasons. First, patients with an asymptomatic hernia may not seek medical help unless a closely and structured follow-up examination is established. However, in larger series with a TSH rate of 0% after single-port cholecystectomy,^1,2,10,11 information on how the follow-up visit was conducted (ultrasound, clinical examination, information provided by the primary physician, telephone call only, etc.) is poorly reported. Second, as concluded by Coda et al., ¹² a TSH is a late observation compared to the “standard” follow-up assessment after gallbladder surgery, and therefore often remains undiagnosed in affected patients, and unreported in series with a limited follow-up period. Finally, a certain relationship between the trocar size and the incidence of TSH seems reasonable. ⁶ Thus it is very likely that the larger fascial incision for trocar placement in SPS will certainly not result in a decreased rate of TSH, when compared with standard multiport laparoscopy.

It has to be taken into consideration that there is still a lack of high-evidence data for the incidence of TSH after standard multiport laparoscopy. In a systematic review of the literature, Helgstrand et al. ⁶ identified three large retrospective studies on this topic rating the incidence of TSH from 0.2% to 5.2%. Of these three studies, only one reported on a systematic follow-up after standard laparoscopic cholecystectomy including 765 patients. These authors found out that 5.2% (n=40) of the patients developed a hernia after standard laparoscopic cholecystectomy.

To date, only few cases of TSH after single-port cholecystectomy have been published.^13,14 In the series reported by Romanelli et al., ¹³ 1 out of 22 patients experienced an incarcerated Richter's hernia after single-port cholecystectomy requiring (urgently) reoperation and small bowel resection. However, the authors explained this complication by a “technical error at closure of the fascial opening.” Ma et al. ¹⁴ reported a case of TSH after single-port cholecystectomy in a patient with ascites, requiring subsequent repair after 6 months postoperatively. Thus, the current literature data let us believe that the rare cases of TSH after single-port cholecystectomy may be attributable to technical failures or to patients' major comorbidity, and are not associated with the access technique per se. In contrast, in our series, the patient who experienced a TSH was a normal-weight and healthy woman, and we are not aware of any technical error at the closure of the fascial incision during primary surgery. Neither did she reveal any signs of subcutaneous wound infection in the early postoperative course. Thus, we cannot provide a reasonable explanation for the observed complication. Although it is yet unknown if late-absorbable suture material will help to prevent TSH, as has been demonstrated for open surgery, ¹⁵ after this complication, we changed our closure technique now using PDS 1 instead of Vicryl 1. A long-term follow-up of these patients is provided in order to gain reliable data regarding this issue.

In conclusion, although potentially biased by a relatively small number of included patients, our study provides evidence that TSH after single-port cholecystectomy is (i) not less frequent when compared with standard laparoscopy, (ii) not as infrequent as suggested by the current literature (Antoniou et al. ⁷ ), and (iii) not only associated with technical failure or patients' comorbidity.