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Surg Endosc (2001) 15: 663–666

DOI: 10.1007/s004640080146

© Springer-Verlag New York Inc. 2001

Risk factors and the prevalence of trocar site herniation after

laparoscopic fundoplication
D. J. Bowrey, D. Blom, P. F. Crookes, C. G. Bremner, J. L. M. Johansson, R. V. Lord, J. A. Hagen,
S. R. DeMeester, T. R. DeMeester, J. H. Peters
Department of Surgery, University of Southern California, HCC Suite 514, 1510 San Pablo St, Los Angeles, CA 90033-4612, USA

Received: 23 August 2000/Accepted in final form: 27 September 2000/Online publication: 11 May 2001

Abstract Key words: Fundoplication — Hernia — Laparoscopy —

Background: Although there have been case reports de- Postoperative complications
scribing trocar site herniation after laparoscopic fundopli-
cation, its overall prevalence and the risk factors for its
development are unclear.
Methods: The records of 320 patients undergoing primary
laparoscopic fundoplication as treatment for gastroesopha- Incisional herniation is a common sequela to open abdomi-
geal reflex disease (GERD) or hiatal hernia between 1991 nal surgery, affecting 5–15% of patients. The reported
and 1999 were reviewed retrospectively. Placement of the prevalence of this complication varies between studies, de-
initial supraumbilical trocar was by the open Hassan tech- pending upon the type of incision employed, the patient
nique in all patients. group studied, and the duration of follow-up [3, 4, 5, 8, 10,
Results: Nine patients (five male) with a mean age 54 years 11, 13, 16, 21, 23, 26, 29]. It is commonly held that the
(range, 37–75) developed trocar site herniation, for an over- frequency of incisional herniation has been reduced since
all prevalence of 3%. The mean interval between surgery the introduction of minimal access surgery.
and diagnosis was 12 months (range, 4–21). In all patients, Although there have been a number of case reports de
the hernia occurred at the supraumbilical camera port site. scribing herniation at laparoscopic trocar sites [6, 7, 9, 12, 14,
Patients with trocar hernias tended to have a higher body 19, 20, 22, 24, 27, 28, 30], there have been surprisingly few
mass index (BMI) than those without hernias (mean BMI, studies [1, 15, 17, 18, 23] examining the exact frequency of
29.4 kg/m2 vs 27.2 kg/m2, p ⳱ 0.13). None of the patients this complication after laparoscopic surgery and none that
developed intestinal obstruction as a consequence of her- have specifically addressed its frequency after laparoscopic
niation. To date, all but one of the hernias have been re- fundoplication. Therefore, we set out to ascertain the fre-
paired. Six of them required the insertion of a prosthetic quency of trocar site herniation in a cohort of patients who
mesh. had undergone laparoscopic fundoplication and second to
Conclusions: The prevalence of trocar site herniation after examine the characteristics of affected individuals so that
laparoscopic fundoplication was minimal at 3%. All hernias any putative risk factors for the development of trocar site
occurred at the midline supraumbilical port, the only site herniation could be identified.
where open trocar insertion was employed. As a conse-
quence of these observations, we have developed a new
method of open trocar placement. This method utilizes a Patients and methods
paramedian skin incision and separate fascial incisions
through anterior and posterior rectus sheathes, with retrac- Study population
tion of the rectus abdominis muscle laterally.
The study population was comprised of 320 patients undergoing primary
laparoscopic fundoplication as treatment for gastroesophageal reflux dis-
ease (GERD) (n ⳱ 292) or paraesophageal hiatal hernia (n ⳱ 28) between
the years 1991 and 1999. The case records were reviewed retrospectively
and those patients who developed incisional herniation identified. For all
Presented at the annual meeting of the Society of American Gastrointes- patients, the following information was extracted from the case records:
tinal Endoscopic Surgeons (SAGES), Atlanta, GA, USA, 29 March– age, sex, body mass index (BMI), past medical/surgical history, and smok-
1 April 2000 ing history. Standard office follow-up for all patients after laparoscopic
Correspondence to: J. H. Peters fundoplication was 6 weeks from hospital discharge. Subsequent follow-up

Table 1. Characteristics of patients developing trocar site hernias

BMI Preexisting Intervala

Age/sex (Kg/m2) Prior abdominal surgery Pulmonary comorbidity hernia (mo)

37/M 27.1 — Current smoker (26 pack-years) No 10

40/M 28.7 — — No 5
46/F 23.5 Hysterectomy, Caesarean section Ex-smoker (30 pack-years) No 19
50/M 34.3 — — No 19
52/M 26.1 — — No 4
53/F 45.2 Open cholecystectomy — No 6
61/M 25.9 Appendectomy Ex-smoker (25 pack-years) No 14
72/F 28.5 Open cholecystectomy, hysterectomy Ex-smoker (45 pack-years) Yes 7
75/F 25.5 Hysterectomy — No 21

M, male; F, female; BMI, body mass index

Denotes interval between antireflux surgery and diagnosis of trocar hernia


At a mean follow-up time of 12 months (range, 6 weeks to

81 months), nine patients (five male) with a mean age of 54
years (range, 37–75) had developed trocar site herniation,
for an overall prevalence of 3% (nine of 320). Table 1
summarizes the characteristics of these nine patients. Seven
trocar hernias occurred after laparoscopic fundoplication for
gastroesophageal reflux (seven of 292, or 2%), and two
occurred after fundoplication coupled with paraesophageal
hernia repair (two of 28, or 7%). In all patients, herniation
affected the supraumbilical port site, the only location
where open trocar insertion was employed. There was a
trend for patients with trocar hernias to have a higher body
mass index than those without hernias (mean BMI, 29.4
Fig. 1. Positioning of the trocars for laparoscopic fundoplication. kg/m2 vs 27.2 kg/m2, p ⳱ 0.13). None of the patients de-
veloped intestinal obstruction as a consequence of hernia-
tion. On average, the hernia was detected 12 months fol-
was by the referring clinician. Patients who required conversion to open lowing surgery (range, 4–12). To date, all but one of the
fundoplication, those who underwent revisional antireflux surgery, and
those who failed to attend for postoperative follow-up were excluded from hernias have been repaired; six of them required the inser-
the analysis. tion of a prosthetic mesh. One patient declined further sur-
Trocar insertion and wound closure
The technique of laparoscopic fundoplication that we followed has been Discussion
detailed previously [2]. Five 10-mm ports were used (Fig. 1). Sharp cutting
disposable trocars (Ethicon Endo-Surgery, Cincinnati, OH, USA) were The current study identified a 3% minimum prevalence of
employed, with trocar positioning as follows:
trocar site herniation after laparoscopic fundoplication. This
1. The camera was placed above the umbilicus, one-third of the distance to figure is in close agreement with four previous studies ex-
the xiphoid process. In all patients, the camera port was the first trocar
introduced. The open (Hassan) method was always followed.
amining the frequency of incisional herniation after laparo-
2. The surgeon’s right and left-handed trocars were placed in the right and scopic abdominal surgery (1–2%) [1, 15, 17, 18, 23]. Thus,
left midclavicular lines, 2–3 in below the costal margin. the risk of incisional herniation is approximately three times
3. The right-sided liver retractor was placed in the right midabdomen in less after laparoscopic fundoplication than after open fun-
the midclavicular line at or slightly below the camera port. doplication.
4. A second retraction port was placed at the level of the umbilicus in the
left anterior axillary line. All hernias affected the supraumbilical port site, the
only place where open trocar insertion was employed. Other
At the end of the procedure, the two lower lateral port sites were closed
using the fascial closure device (Advanced Surgical). The rectus sheath of
investigators have reported a similar predilection for her-
the camera port site was closed with three interrupted 0 Vicryl sutures. No niation to affect the midline port [20]. Moreover, this ob-
fascial closure of the two upper port sites was performed. servation is in keeping with the findings of earlier studies of
open abdominal surgery that examined the risk of incisional
herniation after midline and paramedian incisions [5, 13].
Statistics Kendall [13] randomized 349 patients undergoing laparot-
Since the continuous data followed a normal distribution, parametric tests
omy to one of the following three groups: (a) paramedian
were employed. Comparison of proportions was by the chi-square test. incision with layered closure, (b) midline incision with mass
Significance was assumed at the 5% level. closure, or (c) midline incision with layered closure. After

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