Surg Endosc (2008) 22:2724–2727 DOI 10.1007/s00464-008-9768-4
Trocar-site hernia as a typical postoperative complication of minimally invasive surgery among preschool children K. Paya Æ J. Wurm Æ M. Fakhari Æ R. Felder-Puig Æ S. Puig
Received: 7 May 2007 / Accepted: 14 November 2007 / Published online: 13 February 2008 Ó Springer Science+Business Media, LLC 2008
Abstract Background Minimally invasive surgery (MIS) in preschool children (\5 years of age) is not common yet, and few reports evaluating typical complications are available. Trocar site hernias are well described in adult patients but also have been reported for preschool children. The goal of our study was to determine incidence and relevance of trocar site hernias as complications of minimally invasive surgery in preschool children. Methods Retrospective analysis of all pediatric patients who underwent minimally invasive surgery at a single institution. Review of the literature. Results Trocar site hernias are significantly more frequent in preschool children than in older ones (p = 0.006). Complication rates at all are not significantly different. Trocar site hernias in infants are mainly of type 3 (omental protrusion) and occur within the first postoperative week.
K. Paya (&) Department of Surgery, Medical University of Vienna, Waehringerguertel 18-20, Vienna, Austria e-mail:
[email protected] J. Wurm Department of Pediatric Surgery, Landes-Frauen-u Kinderklinik, Linz, Austria M. Fakhari Department of Pediatric Surgery, SMZO-Donauspital, Vienna, Austria R. Felder-Puig St. Anna Kinderspital, Vienna, Austria S. Puig Research Program for Evidence based Medical Diagnostics, Paracelsus Private University, Salzburg, Austria
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Conclusion Meticulous suturing of all layers (particularely the peritoneum) even in small incisions (2 mm) is recommended to prevent omental protrusion at trocar site in children up to 5 years of age. Keywords Endoscopy Infant laparoscopy Pediatric Trocar-site hernia
Trocar-site hernias are a well-known postoperative complication associated with adult laparoscopic surgery [1–12]. The incidence reported for adults is 0.02% [5] to 22%[7]. To date, no data are available for infants. Only a few case reports of pediatric patients [13–15] and one series including 574 patients ages 0 to 19 years [16] have been published. None of these reports differentiate between very young children with their special physiologic and anatomic features and older children or adolescents, who are more similar to adults. In particular, there is no report that evaluates complications of laparoscopy for the anatomically and physiologically different group of preschool children.
Patients and methods We retrospectively reviewed all laparoscopic procedures performed at a pediatric surgical tertiary care unit during a period of 4 years. Cases were stratified into two groups: group A (age, B5 years) and group B (age, [5 years). For both groups, severe postoperative complications observed up to 12 months after intervention were assessed. For statistical analysis, we used Fisher’s exact test. The level of significance was set at a p value of 0.05 or less.
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Results
Technical aspects
A total of 293 laparoscopic procedures for children (age, 0–18 years) were performed with 644 trocar-site incisions. Of the 293 patients, 53 (18.1%) were younger than 5 year (group A), and 240 (81.9%) were 5 years old or older (group B). The mean age at intervention for group A was 1.7 years (range, 7 days to 4.5 years). The interventional procedures for these 53 patients included laparoscopies for undescended testis (n = 28), prolonged neonatal jaundice (n = 5), and other causes such as intersex condition, unclear urogenital malformation, ovarian tumor, and Ladd’s bands (n = 11). Laparoscopic appendectomy for appendicitis was performed for nine patients, six of whom already had presented with perforation. Three laparoscopies (involving Ladd’s bands, neonatal jaundice) had to be converted to open surgery. The mean hospital stay was 4.2 days (range, 2–7 days). The mean age for group B was 12.5 years (range, 5.1– 18.5 years). The procedures performed were appendectomies (n = 187), diagnostic laparoscopies for various conditions including minor interventions such as deroofing of ovarian cysts, partial resection of omentum in idiopathic omental infarction, freeing of adhesions, excision of urachal cyst, resection of Meckel’s diverticulum, undescended testes, biopsies, and the like (n = 46), and cholecystectomies (n = 7). In both age groups, eight severe postoperative complications (2.7%) occurred for eight different patients. The complications included three trocar-site hernias (all 3 with omental prolaps), two intraabdominal abscesses, two bile leaks, and one omphalitis. Of those eight complications, five occurred in group A and three in group B (9.4% vs 1.3%). The difference was not significant (p = 0.16). No relationship between number of trocar incisions and trocarsite hernia could be identified, except that the number of trocar-site hernias was significantly higher in group A than in group B (p = 0.006). In all cases, the lateral incision was affected after insertion of each a 2-, 3-, and 5-mm trocar, respectively. This seemed unrelated to the particular procedure performed (1 appendectomy, 1 laparoscopic cholangiography, 1 diagnostic laparoscopy in cryptorchidism) or the size of the trocar used. Repair was performed by resecting the herniated omentum and pushing back the stump to the abdominal cavity in all cases. Thereafter, the peritoneum and fascia were closed separately. The repair procedure required general anesthesia for one patient, and sedation using midazolam and local analgesia with xylocaine for the remaining two patients. There was no recurrence, and further history was uneventful for all the patients.
In all the patients, the trocar used was 2 to 5 mm in size with three sharp-edged or pointedly round tips. The mean intraabdominal pressure was 7.5 mmHg for insufflation of carbon dioxide preheated to 37°C. In 90% of the cases, we used three trocars, the first at the umbilical region and the remaining two at the right and left abdominal wall caudally in the umbilical line. The exception involved laparoscopic cholangiographies, for which we inserted the trocars in the upper midline and right upper quadrant of the abdomen. Insertion of the first trocar (periumbilical) was performed in an open manner (Hasson). Trocar closure at the insertion site of the first trocar was performed using double-layer sutures (peritoneum and fascia together first, skin second). At the remaining trocar sites, closure always used one single suture grasping all layers.
Discussion Incisional hernias in adult surgery, as reported by U.S. laparoscopic gynecologists, occur in 0.02% of patients [5]. Other large studies show incidence rates of 0.5% [9], 1.2% [17], 1.5% [18], and 2% [8]. In a small sample of 27 patients, incisional hernias were observed in as many as 22% of the patients [7]. For children and adolescents up to 19 years of age, there is only one published series, reporting an incidence of 0.3% (2 of 574 patients) [16]. However, results from adolescents and adults cannot simply be transferred to preschool children. In fact, laparoscopic techniques used for newborns and infants have different features, ranging from anesthesiology to the choice of instruments. Also, the rate and type of complications seem to be different, but the literature on this is sparse. Our clinical experience suggests that trocarsite hernia may be a typical complication in younger patients, and this became the objective of our study. In adult surgery, trocar sites usually are closed by single suturing of the peritoneum and deep fascia with absorbable sutures, whereas the skin is sutured separately with absorbable or nonabsorbable sutures [19]. Incisions smaller than 5 mm and larger incisions are not closed by separate fascial sutures [5, 20]. Only one transcutaneous suture is used. It is recommended for midline incisions that the fascia always be closed using separate sutures. The recommendations for lateral incisions are different. There is some evidence that oblique trocar insertion at the lateral abdominal wall exclusively prohibits herniation [3, 20]. In preschool children, the abdominal wall is quite thin. The abdominal muscles are weak, and even oblique trocar insertion passes nearly straight through the abdominal wall. Therefore, the defect in the different layers does
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not necessarily misalign and prevent herniation as it would with true oblique insertion channels. In infants, the trocars used are 2 or 3 mm, up to a maximum of 5 mm. Therefore, often only the umbilical insertion wound is closed by fascial and cutaneous sutures, whereas the tiny incisions at the lateral abdomen (e.g., Munro point) are closed by one stitch that tries to catch all layers together. It was surprising to find omental hernias (actually protrusion in front of the abdominal wall) in three cases 3 and 4 days after intervention. This is a rarely described entity that occurs primarily when small ports are used [15, 21]. Tonouchi et al. [12] stress that the type of trocar hernia should be clearly classified for better management of laparoscopic procedures. We agree and would classify these hernias in preschool children as type 3 (special type: dehiscence of whole abdominal wall, protrusion on intestine and/or omentum). However, it is an early onset type because all the omental protrusions occurred within the first postoperative week. A review of the literature showed very few reports describing this complication. To date, its relatively high incidence in relation to other postoperative complications in infants has not been demonstrated. In adults, one large survey [5] showed an incisional herniation rate of 21 per 100.000 (0.02%). Another review [12] found only three case reports of omental protrusion. One-third of the surgeons participating in the survey did not suture the fascia even with trocar sites larger than 10 mm. We found two case reports on incarcerated small bowel hernia due to 5mm trocar incisions in pediatric patients younger than 5 years [13, 14], and one report of five postoperative complications, two of which were omental hernias [16]. This would represent 28.5% of the postoperative complications for this group (2 of 7). Unfortunately, however, Chen et al. [16] does not mention the age of the two children with omental herniation. In a more recent publication, Yee and Duel [15] report one case of omental herniation in a 19-month-old infant. In our study, three of five postoperative complications in preschool children were omental hernias. The overall number of cases with this complication is reportedly very low, reflecting the high level of minimally invasive surgery in infants on the one hand, but limiting statistical power on the other hand. Also, we did not match the samples for different conditions because of our retrospective design to avoid additional bias. However, our data represent clinical reality. Further meticulous observations, reports, and metaanalyses for this group of patients are necessary to clarify the true role of trocar-site hernias. In our study minimally invasive surgery for infants does not show more postoperative complications than among older children and adolescents, giving evidence for the
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safety of the procedure itself. Omental herniation, a type 3 complication according to the classification of Tonouchi et al. [12], may be an expected postoperative complication of laparoscopic surgery for young children. In adult surgery, incisions smaller than 5 mm are sometimes not sutured at all. In infants, they are sutured by only one transcutaneous stitch. According to our observations, this cannot be recommended any longer for young children.
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