Effect of internal ligation on the occurrence of trocar site hernia after laparoscopic sleeve gastrectomy

Abstract

Aims: Nowadays, laparoscopic sleeve gastrectomy (LSG) has become the most commonly performed bariatric surgical method. One of the complications seen after LSG is trocar site hernia (TSH). The aim of this study is to identify the risk factors for TSHs after LSG and to investigate the effect of internal ligation of the trocar entry site using energy-based vessel-sealing device (LigaSure™) on preventing TSH occurrence. Methods: The records of 841 patients who underwent LSG between January 2021 and October 2023 at Altınbaş University Faculty of Medicine Medicalpark Hospital were reviewed. A total of 244 patients were included in the study. All surgeries were performed by the same surgical team under identical conditions. In all patients, the right trocar site used to remove the stomach from the abdomen was expanded with a Kocher clamp. The right and left 12 mm trocar entry sites were ligated internally using LigaSure. The patients' age, gender, body-mass index (BMI), diabetes mellitus (DM), hypertension (HT), dyslipidemia, wound site infections, smoking status, chronic obstructive pulmonary disease (COPD), and constipation were evaluated. All patients were followed up at the 3rd, 6th, and 12th months following the LSG surgery. Physical examinations and ultrasound scans were performed to detect the presence of TSH. Results: In the analysis of 244 patients, 150 (61.5%) were female, 94 (38.5%) were male, and their ages ranged from 18 to 72 years old. The average age was 39.28±12.27 years old. The BMI ranged from 35.1 kg/m² to 63.9 kg/m², with an average of 43.16±5.40 kg/m². HT was present in 32% of the cases, diabetes in 35.2%, dyslipidemia in 38.9%, and COPD in 6.1%. Constipation was reported in 26.6% of the patients, and 41.4% were smokers. Wound infections were seen in 2 cases (0.8%). At the 3-month follow up, no TSHs were detected. At the 6-month post-surgical follow-up, one patient had a TSH, and one more was detected in an ultrasound scan performed after 1 year of the LSG surgery. The hernias identified were at the right trocar site, and none of them were symptomatic. There was no statistically significant correlation between gender, BMI, HT, diabetes, dyslipidemia, smoking, and the occurrence of hernia (p>0.05). The mean age of patients with a detected hernia (66.0±2.83 years) was statistically significantly higher than that of patients without hernia (39.06±12.07 years) (p:0.020; p<0.05). The hernia rate in COPD patients (13.3%) was statistically significantly higher compared to those without COPD (0%) (p: 0.004; p<0.05). Although the hernia rate in patients with constipation (3.1%) was higher than in those without constipation (0%), this difference was not statistically significant (p: 0.070; p>0.05). The hernia rate in patients with wound site infections was statistically significantly higher than in those without wound site infections (p: 0.016; p<0.05). In literature, studies report that the incidence of TSH ranges from 4% to 39%. In our study, this rate was less than 1%. Conclusion: Advanced age, COPD, constipation, and wound site infection were identified as risk factors for TSH. Internal ligation of the trocar entry site after LSG is an effective method for reducing the rate of TSH.

Keywords

• Laparoscopy
• sleeve gastrectomy
• trocar site hernia
• wound infection

Ethical Statement

Altinbas University Health Sciences Scientific Research Ethics Committee (Date: 2024, Decision No: 27)

References

1. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (1 March 2024)
2. Scozzari G, Zanini M, Cravero F, Passera R, Rebecchi F, Morino M. High incidence of trocar site hernia after laparoscopic or robotic Roux-en-Y gastric bypass. Surg Endosc. 2014;28(10):2890-2898. doi:10.1007/s00464-014-3543-5
3. Karampinis I, Lion E, Hetjens S, et al. Trocar site HERnias after bariatric laparoscopic surgery (HERBALS): a prospective cohort study. Obes Surg. 2020;30(5):1820-1826. doi:10.1007/s11695-020-04400-y
4. Singal R, Zaman M, Mittal A, Singal S, Sandhu K, Mittal A. No need of fascia closure to reduce trocar site hernia rate in laparoscopic surgery: a prospective study of 200 non-obese patients. Gastroenterol Res. 2016; 9(4-5):70-73. doi:10.14740/gr715w
5. Comajuncosas JHJ, Gris P, Jimeno J, et al. Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study. Am J Surg. 2014;207(1):1-6. doi:10. 1016/j.amjsurg.2013.05.010
6. Ciscar A, Badia JM, Novell F, Bolívar S, Mans E. Incidence and risk factors for trocar-site incisional hernia detected by clinical and ultrasound examination: a prospective observational study. BMC Surg. 2020;20(1):330. doi:10.1186/s12893-020-01000-6
7. Nofal MN, Yousef AJ, Hamdan FF, Oudat AH. Characteristics of trocar site hernia after laparoscopic cholecystectomy. Sci Rep. 2020;10(1):2868. doi:10.1038/s41598-020-59721-w
8. Zhu YP, Liang S, Zhu L, Sun ZJ, Lang JH.Trocar-site hernia after gynecological laparoscopic surgery: a 20-year, singlecenter experience. Chin Med J (Engl). 2019;132(22):2677-2683. doi:10.1097/CM9. 0000000000000510

9. Swank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman A. Systematic review of trocar-site hernia. Br J Surg. 2012;99(3):315-323. doi:10.1002/bjs.7836
10. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg. 2004;139(11):1248-1256. doi:10.1001/archsurg.139.11.1248
11. Ahlqvist S, Björk D, Weisby L, Israelsson LA, Cengiz Y. Trocar site hernia after gastric bypass. Surg Technol Int. 2017;30:170-174.
12. Baucom RB, Beck WC, Holzman MD, Sharp KW, Nealon WH, Poulose BK (2014) Prospective evaluation of surgeon physical examination for detection of incisional hernias. J Am Coll Surg. 2014;218(3):363-366. doi: 10.1016/j.jamcollsurg.2013.12. 007
13. Karampinis I, Lion E, Grilli M, et al. Trocar site hernias in bariatric surgery-an underestimated issue: a qualitative systematic review and meta-analysis. Obes Surg. 2019;29(3):1049-1057. doi:10.1007/s11695-018-03687-2
14. Üstünyurt E, Taşgöz FM, Tiğrak S. Asymptomatic trocar site hernias: an underestimated complication of laparoscopy. Turk J Obstet Gynecol. 2020;17(3):202-208. doi:10.4274/tjod.galenos.2020.70952
15. Deerenberg EB, Nadia A, Henriksen NA, et al. Updated guideline for closure of abdominal wall incisions from the European and American hernia societies. Br J Surg. 2022;109(12):1239-1250. doi:10.1093/bjs/znac 302
16. Omar I, Miller K, Madhok B, et al. The first international delphi consensus statement on laparoscopic gastrointestinal surgery. Int J Surg. 2022;104:106766. doi:10.1016/j. ijsu.2022.106766