10 Jan 2025 Suture Every Trocar Incision Above 10 mm!
As laparoscopic surgery becomes increasingly widespread, a new type of hernia has emerged: Trocar Site Hernia. These hernias are most commonly observed at trocar entry points larger than 10 mm, with an incidence rate of 1-3%. Although rare, hernias at 5 mm and 8 mm trocar sites have also been reported.
Certain patient-related factors increase the risk, including obesity, smoking, and diabetes. However, local factors play a significant role as well:
- Trocar entry points larger than 10 mm
- Surgery of long duration
- Excessive manipulation with the port
- Using trocar sites for drain placement
- Entry below the arcuate line
- Trocar site infections
Particularly with bladed trocars, the cutting mechanism creates a fascial incision wider than the trocar diameter itself. During surgery, manipulations often enlarge this incision further, and localised mechanical trauma can damage the fascia and impair healing. For example, a 5 mm trocar site may expand to 7-8 mm, and a 10 mm site may reach 13-14 mm. This is why blunt trocars are strongly recommended. These trocars not only reduce fascial injury but also lower the risk of organ damage during entry. Click to read my blog post regarding blunt trocars!
The umbilical area is often used for the camera entry and requires a 10 mm trocar. However, due to its anatomical weakness, the umbilical region is more prone to hernia formation. Additionally, this site is frequently expanded to remove specimens (e.g., gallbladder or appendix, bowel segment, etc.), further increasing the risk. To mitigate this, meticulous fascial closure is essential at the end of surgery.
Single-Incision Laparoscopic Surgery (SILS) presents an even greater challenge, with hernia rates reported as high as 15%, an unacceptable figure. Whether these are classified as incisional or trocar site hernias is still debated. Regardless, due to higher postoperative pain and elevated hernia risk, SILS should no longer be performed. In recent years, despite the promotion and technological advancements surrounding single-port robotic platforms, the fundamental truth remains unchanged: SILS inevitably leads to an increased incidence of trocar site hernias. This lesson was learned through our experience with laparoscopic surgery. A recent meta-analysis even concluded that no further evidence is needed to establish this fact. In the summer of 2023, I authored an eye-opening article on eTEP, one of the most popular ventral hernia repair techniques of recent years. Published in the Hernia Journal, it highlighted critical insights into the approach and emphasizes the challenges of the technique. Time has proven me right. It seems my next article will focus on single-port robotic platforms. In fact, I’ve already started writing it!
Closing trocar sites can be technically demanding, especially in obese patients. Suturing the anterior fascia through a small skin incision requires skill. However, practical tools designed specifically for this purpose are available and highly recommended. Using such devices can significantly simplify the process.
I recommend using 2/0 PDS or 2/0 Monomax to suture the fascia.
If a trocar site hernia does occur, it should be treated like any other incisional hernia and repaired accordingly.
