Keywords Obesity · Morbid · Port site hernia · Laparoscopy · Trocar. Introduction ... procedures such as laparoscopic Roux-en-Y gastric bypass. [2]. However ...
Updates in Surgery https://doi.org/10.1007/s13304-017-0501-5
ORIGINAL ARTICLE
Port site hernia after laparoscopic sleeve gastrectomy: a retrospective cohort study of 352 patients Ilhan Ece1 · Huseyin Yilmaz1 · Husnu Alptekin1 · Serdar Yormaz1 · Bayram Colak1 · Mustafa Sahin1 Received: 9 August 2017 / Accepted: 8 November 2017 © Italian Society of Surgery (SIC) 2017
Abstract Port site hernia (PSH) following laparoscopic procedures is a rare but serious complication. The aim of this study was to evaluate the rate of PSH after laparoscopic sleeve gastrectomy (LSG), and the efficacy of closure of the port site as a means of preventing PSH. A retrospective analysis was performed on 386 patients who underwent LSG between December 2009 and January 2015. 352 (91.2%) of the patient were followed up for at least 24 months. In the first 206 patients, the fascial layers of the trocar incisions were not closed, while in the next 146 cases, routine closure of the trocar sites was performed. The patients were reviewed in relation to demographics, comorbidities, complications, percentage of excess weight loss, and rates of PSH. The total cohort consisted of 220 female and 132 male patients with a mean age of 36.2 ± 12.3 years. Demographic data, initial BMI, and comorbidities were similar for the patients in both groups. The closure of the fascia was caused by the prolonged duration of the operation with no significant difference. The unclosed fascial defects were associated with a significantly increased incidence of PSH (1.3 vs. 3.9%, p 60 kg/m2 were not accepted as an appropriate candidate for LSG.
Operative procedure After the prophylaxis of deep vein thrombosis (Enoxaparin sodium 6000 anti-Xa IU 60 mg), and chemoprophylaxis (cefazolin 2 g), all operations were performed under general anesthesia by means of a four-port technique. Pneumoperitoneum was established by insertion of the first supra-umbilical 10-mm trocar after the abdominal wall was lifted. Two additional working 15-mm bladed trocars were placed on the right and left upper sides of the camera port. A 5-mm port was inserted into the subxiphoid area for liver retraction. Gastric transection was performed 2 cm from the pylorus toward the angle of His under the guidance of a size 36 French bougie by means of 60 mm linear staplers (EndoGIA, Covidien, USA). At the end of the surgical procedure, the left 15-mm port site was enlarged slightly to around the size of two fingertips to allow easier specimen extraction. The stomach remnant was grasped at the caudal tip by a Foerster forceps and was removed through the port site using a gauze sponge as described by Derici et al. [7]. In the first 206 cases (nonclosure group), routine closure of the fascial defects was not performed. In the next 146 patients (closure group), the fascial defects at the 15-mm ports were closed with number 0 absorbable polyglactin (Vicryl™, Ethicon, Belgium) sutures under laparoscopic direct visualization. A trocar site closure device (EndoClose™, Covidien, MA, USA) was used to facilitate and secure the procedure. The patients were regularly followed up at the outpatient clinic for at least 2 years. Surgical site healing, biochemical
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Updates in Surgery
parameters and a complete blood count were evaluated at the first follow-up visit on postoperative day 7. Follow-up visits were performed at 1, 2, 3, 6, 12, and at least annually thereafter. After institutional review board approval, the patients’ data, including each patient’s characteristics, comorbidities, preoperative BMI, percentage of excess weight loss (%EWL), and complications were obtained from hospital charts and office records. The weight loss of the patients was evaluated based on the percentage of excess weight loss (%EWL), which was calculated as follows: [(preoperative weight − follow-up weight)/(preoperative weight − ideal body weight)] × 100. The ideal body weight was calculated by assuming an ideal BMI of 25 kg/m2.
Statistical analysis The demographic data and perioperative data were compared using the Student’s t and Mann–Whitney U tests for continuous variables. Fisher’s exact test was used to determine any statistical significance for the categorical variables. The continuous variables were presented as mean ± standard deviation and the categorical variables were presented as the number (%). The level of significance was set at 0.05.
Results The data for a total of 386 morbidly obese patients who underwent LSG were evaluated in this study. Thirty-four patients were excluded and a total of 352 patients were enclosed in the study. Reasons for exclusion included a failure to follow-up (n = 28), previous laparotomy (n = 5), conversion to open surgery (n = 1). The demographic and preoperative characteristics of the patients are shown in Table 1. There were no statistically significant differences in age, gender distribution, and initial BMI between the two groups. The groups were also similar in terms of preoperative comorbidities and ASA scores. The mean follow-up period was 46.2 ± 6.2 months for the patients in non-closure group and 27.1 ± 4.8 months for those in closure group. The mean follow-up period was also higher in non-closure group. For standardizing the groups, 24 months’ follow-up results were collected for both groups. The overall incidence of PSH was calculated as 2.8% (10 of 352 patients). However, in non-closure group (3.9%; 8 of 206 patients), the PSH rate was significantly higher than that of closure group (1.3%; 2 of 146 patients). The vast majority of PSHs were detected in the left trocar area where the 15-mm port was inserted. Only one PSH was identified in the right trocar area in non-closure group. No hernia was observed in the supra-umbilical trocar site or in the subxiphoid area. All of the PSHs in closure group occurred in diabetic patients. In non-closure group, wound healing was
Updates in Surgery Table 1 Preoperative patients’ characteristics
Table 2 Surgical outcomes and postoperative complications
Variable
Non-closure group (n = 206)
Closure group (n = 146)
p
Variable
Non-closure Closure group (n = 206) group (n = 146)
p
Agea (years) Genderb Female Male Body mass indexa (kg/m2) ASA classificationb I II III Comorbiditiesb Type 2 diabetes Coronary artery disease Hypertension Dyslipidemia Degenerative joint disease COPD
37.2 ± 15.2
35.8 ± 14.6
128 (62.1) 78 (37.9) 45.1 ± 4.9
92 (63.0) 54 (37.0) 44.9 ± 5.1
0.312 0.341
8 (3.9) 45.8 ± 11.4 71.3 ± 15.1
2 (1.3) 54.2 ± 12.3 70.8 ± 14.6
68 (46.5) 50 (34.2) 28 (19.1)
10 (4.8) 11 (5.3) 3 (1.4)
8 (5.5) 8 (5.5) 2 (1.3)
