OBES SURG DOI 10.1007/s11695-016-2285-y
LETTER TO THE EDITOR
Letter to the Editor: Trocar Site Hernia Prevention in Laparoscopic Bariatric Surgery Mohammed Y. F. Aly 1,2 & Wei-Jei Lee 1
# Springer Science+Business Media New York 2016
Dear Sir, We read with interest the article BTrocar port hernias after bariatric surgery^ [1]. We congratulate the authors on their high-quality data and appreciate them for sharing their experience regarding trocar site hernias after bariatric surgery. We have a conflict to some points, and we would like to share our opinion with the authors. The authors concluded that routine closure of trocar sites can be omitted since the incidence of hernia is low in bariatric patients. They reported an incidence of 0.5 % trocar site hernia in their own series, and we see that this incidence is high. Our goal is to reach to a 0 % complication after bariatric surgery. For trocar wounds ≥10 mm, we believe that the muscular layer should be managed and not just the skin and subcutaneous layers be sutured. Many articles postulated that the risk of trocar site hernia is significantly higher when trocar size is ≥10 mm and hence should be closed [2]. As closure of laparoscopic trocar wounds is difficult and time consuming in bariatric patients due to thick fatty layer of the anterior abdominal wall [3], we previously reported an effective method to prevent trocar site hernias without facial closure in 2006 [4]. We used a Surgicel® mesh (oxidized regenerated cellulose hemostat) to be inserted within the muscle layer of trocar wounds of 10 and 12 mm diameter. Our initial results of trocar site hernia were 0.33 % (2/621 patients) in mini-gastric bypass and 0 % (0/142) in
gastric banding [4]. Two years ago, we started to use a new method, omental plug in which a piece of omentum is dissected, separated, and inserted within the muscle layer of each trocar wound more than 10 mm (Figs. 1 and 2). This method has the advantages of easy application and cost effectiveness. Also, omentum is a human tissue to avoid the use of foreign body. The size of the omental plug is fashioned to fill the whole space and hence avoid wound seroma. Bruker M et al. [5] reported the fate of trans planted autologous fat in animal model, and he observed a significant inflammatory response in the early phases with evidence of neovascularization. In our experience, around 5000 bariatric procedures were performed in our center from 2006 till now. Surgicel® plug was used early and omental plug was used in the recent 2 years. Only one case of trocar site hernia (0.02 %) was experienced in this period. We conclude that trocar site wounds ≥ 10 mm should be closed to minimize the risk of hernia. We also introduce the two methods of Surgicel® and omental plug for prevention of trocar site hernias without facial closure with
* Wei-Jei Lee
[email protected] 1
Department of Surgery, Min-Sheng General Hospital, 168, Jingguo Rd., Taoyuan Dist., Taoyuan City 33044, Taiwan
2
Department of Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
Fig. 1 Catching the omental plug by grasper
OBES SURG Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent required.
For this type of study, formal consent is not
References 1. Fig. 2 Omental plug is inserted within trocar wound
documented favorable outcomes along the short- and longterm follow-up.
2.
3. Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest.
4.
Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964
5.
Coblijn UK, de Raaff CA, van Wagensveld BA, van Tets WF, de Castro SM. Trocar port hernias after bariatric surgery. Obes Surg. 2016;26(3):546–51. Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surgeon. 2011;9(4):218–24. Durai R, Ng PC. Novel methods of closing 10-mm laparoscopic port-site wounds. J Laparoendosc Adv Surg Tech A. 2009;19(6): 791–3. Chiu CC, Lee WJ, Wang W, Wei PL, Huang MT. Prevention of trocar-wound hernia in laparoscopic bariatric operations. Obes Surg. 2006;16(7):913–8. Brucker M, Sati S, Spangenberger A, Weinzweig J. Long-term fate of transplanted autologous fat in a novel rabbit facial model. Plast Reconstr Surg. 2008;122(3):749–54.
