Herniation of the trocar site after laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: a first case report after 40 years of single-center experience and a brief review of the literature | BMC Women’s Health
This was our first experience with TSH after laparoscopic salpingo-oophorectomy, although we have performed approximately 10,436 laparoscopic surgeries in 40 years, including approximately 4,933 adnexal surgeries since 1981 (Fig. 6). In 1994, the American Association of Gynecologic Laparoscopists published a large-scale study of 4,385,000 patients which determined that the incidence of TSH was 0.021% . Thus, TSH is a rare postoperative complication of laparoscopic gynecologic surgery. Although our patient was able to undergo minimally invasive hernia repair by extending the 12mm port incision after TSH which is a rare event, life-threatening complications such as bowel obstruction and strangulation can lead to significant morbidity and mortality if not treated promptly. .
The risk of TSH increases with respect to specific patient factors, such as obesity, age, wound infection, diabetes, and smoking, and factors related to surgery, such as operating time. , excessive manipulation of the trocar insertion port, port diameter, insertion site, and incomplete suturing of the fascia and peritoneum [13,14,15,16]. A previous systematic review recommended closing all fascial defects> 10mm and closing defects> 5mm when the orifices were subjected to excessive manipulation. . In contrast, one study reported a 0% TSH incidence rate with 5mm and 10mm port sites after 4.94 years of follow-up. . Another study demonstrated 0% incidence rate of TSH with 10mm ports, suggesting fascial closure was unnecessary . In a recent review, Guiterrez et al. concluded that there was no difference in TSH levels if the fascia was left open or closed with orifices 10 mm . In contrast, the location of the trocar may be a risk factor for TSH. Due to the inherent anatomical weakness of the paraumbilical region, midline offline trocars had lower TSH incidence rates than midline trocars. [4, 19]. Additionally, even without fascial closure, bladeless trocars were associated with decreased bowel obstruction and hernia formation. [20, 21]. Guiterrez et al. also established that the use of bladeless trocars, similar to those used in our method, was associated with lower TSH levels compared to bladed trocars. Based on the aforementioned evidence, we used bladeless trocars with a 12mm orifice in an offline midline location to prevent TSH.
Female gender tended to be associated with a high incidence of TSH [3, 22, 23]. In particular, older women may be predisposed to TSH due to a weaker fascia and less muscular abdominal wall than older men. . Additionally, a high BMI may also be a risk factor for TSH due to increased intra-abdominal pressure.  and the difficulties associated with making a full-thickness closure . In this case, none of the above risk factors were identified, as the patient had a low BMI and was a middle-aged woman. As discussed previously, although fascial closure had not been achieved in the previous 40 years, in this case we could not preoperatively predict the onset of TSH and luckily TSH could be diagnosed quickly.
A recent large retrospective study reported that the total postoperative TSH level among gynecologic laparoscopic procedures over the past 20 years was approximately 0.016% (9 / 55,244) . The study established that the TSH level was 4/31,778 (0.013%) in laparoscopic salpingo-oophorectomy. This result was similar to that of our study. However, three of the four cases placed the trocar in the midline, and two of the four cases involved laparoscopic single incision surgery (SILS). SILS is a known risk factor for TSH [27, 28] because the ports are introduced through a single 2-4cm incision which is usually found in the umbilicus . Only one of the four patients who presented with TSH had an offline midline trocar placement, as in our case; however, the patient was 79 years old, which was a risk factor for TSH. Considering all this information, the exact cause of TSH in our case remains unknown because the trocar was not placed on the midline, the SILS was not performed and the patient was not an adult plus. age. However, there was always the possibility that excessive manipulation, such as stretching the orifice site during sample removal, would result in TSH.
We have previously reported that the surgical specimen can be removed transvaginally instead of being extracted from the trocar site, as the adenomyotic tissue may be too hard to extract using the 12mm trocar morcellator. [30, 31]. In addition, some surgeons have also opted for vaginal extraction due to improved cosmetic results in some gynecologic laparoscopic surgeries. [32,33,34]. Recently, Huang et al. proposed a shaped incision designed, such as the Y shape, to extract the specimen using an animal model. This technique could reduce the length of the incision and its clinical use could minimize complications associated with the auxiliary incision, such as TSH . All of the above points support the use of the vaginal extraction route in patients at risk of TSH.
Several surgeons have introduced a method of fascial closure that uses a new device and technique to prevent TSH [14, 21, 36]. Although immediate postoperative pain has been avoided with the use of local anesthetics, such as bupivacaine, at the orifice sites during surgery, postoperative abdominal pain has always occurred at the site of fascial closure due to the fascial edge bypass, excessive fascial tension and risk of nerve compression. . Therefore, we hesitated to suture the fascia and only sutured the peritoneum with 2-0 PDS under direct vision while maintaining a pneumoperitoneum (Fig. 7a, b; Supplementary File 1: Movie). The procedure was performed this way because studies have shown that TSH can develop under the fascia; therefore, peritoneal closure is more important than fascial closure . To date, this method has been used in about 50 patients without complications or recurrence. Other cases should be documented and these patients should be followed to determine the long-term prognosis after using this surgical technique.
In conclusion, we understand that TSH is a relatively rare complication of gynecologic laparoscopy. In 40 years of experience, despite improved equipment and more qualified gynecologists, this was our first encounter with TSH. More attention should be paid to the possibility of TSH to ensure prevention of serious problems through early detection and treatment.