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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

INCARCERATED TROCAR SITE: RICHTER'S HERNIA


M Smith, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This case describes the strangulation of small bowel into a trocar site. This classic complication is under-reported in the literature. The knowledge of such a complication and its early diagnosis are important to avoid complications.

2. Keywords


Obstruction, port incision

3. Patient


Female, 50-year-old

4. History of present illness


The patient presents with a classic clinical picture of acute appendicitis. She undergoes a laparoscopic appendectomy uneventfully. A 12 mm trocar is used to apply a mechanical stapler at the base of the appendix, which was described as necrotic.

5. Clinical progression


Postoperative day 4, the patient develops progressive abdominal distension, crampy abdominal pain, nausea and bilious vomiting. She is afebrile.

6. Laboratory values


- WBC: 12 500 / mm3 (N 4000-10 000 / mm3);
- normal chemistries, amylase, lipase.

7. KUB


Dilated small bowel with multiple air fluid levels

8. CT scan


Suspected herniated small bowel into right trocar site with small bowel obstruction

9. Treatment


Laparoscopy: Richter's hernia into trocar site with small bowel obstruction. The incarcerated bowel could not be reduced laparoscopically. Limited exploration of the trocar site confirms findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis is performed. The patient makes an uneventful recovery.

10. Discussion


Trocar site hernias are common and relatively under-reported. In a mail-in study by Montz et al. (1994), composed of over 3,000 responses, 933 hernias were reported out of an estimated 4,385,000 laparoscopic surgeries (estimated incidence of 21/100,000 procedures). The clinical presentation of trocar site hernias is variable. Often, the swelling and pain at the incision site that may be hard to differentiate from a hematoma and postoperative ileus. Although most hernias present within 10 days from the procedures, delayed hernias have been reported up to a year from the initial operation (Boike et al. , 1995). CT scanning is a very helpful adjunct in these situations to differentiate hematoma from incarcerated small bowel and ileus from small bowel obstruction. Frager et al. (1995), using CT scanning, were able to correctly differentiate ileus from SBO in 36 consecutive patients. While most authors recommend closure of all fascial defects, attempts at closure do not prevent a hernia from occurring in all cases. In a study of Boike et al. (1995) 8 out of 19 incisional herniations occurred on sites where fascial closure was reported as having been satisfactorily performed. The study of Montz et al. (1994) also reported an 18% incidence of hernias on closed sites. However, 1/3 of surgeons in this study indicated that they never performed fascial closure. We emphasize the importance of closing trocar sites in order to significantly decrease postoperative morbidity and related costs.

11. References


  1. Frager DH, Baer JW, Rothpearl A, Bossart PA. Distinction between postoperative ileus and mechanical bowel obstruction: value of CT compared with clinical and other radiographic findings. AJR 1995;164:891-4.
  2. Montz FJ, Holschneider CH, Munro MG. Incisional hernias following laparoscopy: a survey of the American Association of Gynecologic Laparoscopists. Obstet Gynecol 1994;84:881-4.
  3. Boike GM, Miller CE, Spirtos NM, et al . Incisional bowel hernias after operative laparoscopy. Am J Obstet Gynecol 1995;172:1726-33.