Trocar-Site Hernia After Gynecological Laparoscopic Surgery: A 20-Year Study

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Trocar-Site Hernia After Gynecological Laparoscopic Surgery: A 20-Year, Single-Center Experience

Laparoscopic surgery has become a cornerstone of gynecological practice since the 1990s, offering advantages such as reduced incision size, shorter hospital stays, and fewer complications compared to open procedures. However, trocar-site hernia (TSH) remains a rare but potentially life-threatening complication. This study retrospectively analyzed 55,244 gynecological laparoscopic procedures performed over two decades at Peking Union Medical College Hospital (PUMCH) to identify risk factors for TSH and propose preventive strategies.

Incidence and Demographic Characteristics

The overall incidence of TSH in the study cohort was 0.016% (9/55,244 cases), translating to approximately one case per 6,138 procedures. While rare, TSH carries significant clinical consequences, including intestinal obstruction and bowel necrosis. The average age of affected patients was 53.4 years (range: 35–79 years), with a median body mass index (BMI) of 25.1 kg/m² (range: 17.6–34.0 kg/m²). Among the nine cases, two occurred after single-incision laparoscopic surgery (SILS), while seven followed conventional multiport laparoscopy.

Risk Factor Analysis

Age: Elderly patients (≥60 years) showed a significantly higher TSH incidence (0.112%, 3/2,686 cases) compared to younger patients (<60 years; 0.011%, 6/52,558 cases; P=0.008). Advanced age likely contributes to weakened fascial integrity, increasing susceptibility to hernia formation.

Surgical Approach: SILS was associated with a markedly higher TSH rate (0.357%, 2/534 cases) than conventional laparoscopy (0.013%, 7/54,710 cases; P=0.003). The larger umbilical incision required for SILS (25–40 mm vs. 5–10 mm for conventional ports) and challenges in achieving secure fascial closure likely explain this disparity.

Operative Factors:

  • Port Site: Hernias predominantly occurred at the umbilical site (4/9 cases) and the right lateral port (5/9 cases). The right lateral site’s vulnerability may stem from repeated instrument manipulation during specimen extraction.
  • Fascial Closure: Among conventional laparoscopy cases, hernias developed at both 10-mm (5/7) and 5-mm (2/7) port sites, suggesting that even smaller incisions may require meticulous closure, particularly in high-risk patients.
  • Timing of Onset: Early-onset hernias (within two weeks postoperatively) accounted for seven cases, presenting with acute symptoms like bowel obstruction. Late-onset hernias (two cases) manifested as asymptomatic abdominal masses months to years after SILS.

Clinical Presentation and Management

TSH symptoms included nausea, vomiting, abdominal pain, and palpable masses. Intestinal obstruction was observed in five cases, with one requiring small bowel resection due to necrosis (Figure 3). Diagnostic imaging, primarily computed tomography (CT), confirmed herniation in all symptomatic cases (Figure 2).

All patients underwent surgical repair: eight via laparotomy and one via laparoscopy. The two SILS-related hernias involved omentum protrusion through the umbilical port, whereas conventional laparoscopy cases involved small bowel herniation at lateral or umbilical sites. The interval between initial surgery and hernia diagnosis ranged from 2 days to 2 years, underscoring the need for long-term follow-up in high-risk populations.

Prevention Strategies

  1. Fascial Closure: Meticulous closure of fascial defects ≥10 mm is critical. The study highlights the importance of extending this practice to 5-mm ports at high-risk sites (e.g., right lateral trocar) and SILS umbilical incisions.
  2. Trocar Site Selection: Utilizing the “yellow island” technique—targeting avascular subperitoneal adipose zones—may minimize vascular injury and subsequent fascial weakening.
  3. Minimizing Trocar Manipulation: Reducing instrument exchanges and tissue trauma at port sites can lower hernia risk.
  4. Postoperative Care: Avoiding activities that increase intra-abdominal pressure (e.g., heavy lifting, vigorous coughing) during the early recovery phase is essential, particularly in elderly patients.

Discussion

The low overall TSH incidence aligns with prior reports (0–5.2%), but the heightened risk associated with SILS and advanced age necessitates heightened vigilance. SILS’s cosmetic benefits must be weighed against its higher hernia risk, emphasizing the need for technical refinements in fascial closure. The predominance of right lateral hernias underscores the role of operative technique, as this site is frequently used for instrument access and specimen retrieval.

The study’s retrospective design limits causal inferences, and the actual TSH incidence may be underestimated due to asymptomatic cases or patients seeking care elsewhere. Prospective studies with standardized follow-up protocols are needed to validate these findings and explore additional risk factors, such as BMI, diabetes, and smoking.

Conclusion

This 20-year analysis identifies advanced age and SILS as key risk factors for TSH following gynecological laparoscopy. Preventive measures, including careful port site selection, fascial closure, and minimizing tissue trauma, are critical to mitigating this complication. Surgeons must balance innovation with patient safety, particularly in vulnerable populations.

doi.org/10.1097/CM9.0000000000000510

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