CASE REPORT

Wound dehiscence at a 7-mm port site closed with tissueadhesive

Jason Abbott and Graham PhillipsWomen's Endoscopic Laser Foundation, South Cleveland Hospital, Middlesbrough, UK

ABSTRACT

Objective To describe the herniation of omentum through a 7-mm supra-pubic port site, which had been closed with tissue adhesive, followinglaparoscopic sterilization, requiring repair under general anaesthetic.Setting Minimal access gynaecological surgery unit in a district generalhospital.Subject A 26-year-old multiparous woman who presented with abdominalpain and an omental herniation through her suprapubic port site.Intervention The patient required repeat laparoscopy and digital reduc-tion of the hernia with formal repair of the rectus sheath defect.Conclusion This case of herniation through a midline 7-mm port site mayhave implications for the closure of wounds at laparoscopy. Most gynaecol-ogists do not formally close the rectus sheath at laparoscopic sterilization;however, with the possibility of visceral herniation and vascular compro-mise, this practice may change in the future. It is not clear whether thetissue adhesive had a role in this complication.

Keywords

cyanoacrylate, laparoscopic compli-cation, port-site hernia, tissue adhe-sive.

Correspondence

J. Abbott, Women's Endoscopic LaserFoundation, South Cleveland Hospital,Marton Road Middlesbrough TS4 3BW, UK

Accepted for publication 18 October 1999

INTRODUCTION

There are few reported cases of herniation followinglaparoscopy, and when they have occurred it is usuallythrough a port site of greater than 10 mm1 Theherniated tissue is usually small bowel or omentum.2±7

There have been recommendations that port sitesgreater than 10 mm should be formally closed underdirect vision to prevent this complication fromoccurring, though as yet there is no recommendationfor such closure in smaller port sites.8 Risk factors forherniation include the use of large cannulae, and thepresence of irrigation fluid within the abdominal cavitywhich may help `flush' the abdominal contents outthrough the port site.3

CASE HISTORY

A 26-year-old multiparous woman, with a previoushistory of a cerebral aneurysm, which required clipping

following a small intracerebral haemorrhage, under-went elective laparoscopic sterilization by a standardtechnique using a 10-mm laparoscope introduced intothe peritoneal cavity via an infraumbilical incision. Asecond 7-mm port was placed suprapubically, throughwhich a Filshie clip applicator was positioned. TwoFilshie clips were applied to each tube and afterconfirming that there was no other pelvic or abdom-inal pathology, the wounds were closed using cyan-acrylate tissue adhesive. The patient was discharged thesame day.

Whilst the patient was straining at stool 4 days later,the suprapubic wound opened and yellow tissue wasnoted to be protruding from the wound. The patientpresented to her local accident and emergencydepartment where it was found that her vital signswere normal, the abdomen was soft and there werebowel sounds present. She was then transferred to thedistrict general hospital where the operation wasperformed.

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On her arrival, omentum was clearly evident throughthe suprapubic port site and measured 3 � 4 cm inarea. There was no evidence of other visceral hernia-tion. The patient was in considerable pain and afterreceiving analgesia, was transferred to the operatingtheatre, where a laparoscopy was performed undergeneral anaesthetic.

At laparoscopy it was confirmed that only omentumhad herniated and this was reduced manually and thevascular integrity confirmed. The rectus sheath wasidentified and Allis clips placed on either side. Using a2/0 Ethibond suture on a J needle, the rectus defectwas repaired under direct laparoscopic vision. Theumbilical incision was repaired using 2/0 undyedVicryl, with closure of the fascial layer only. The patientwas discharged the same day, and at follow up 1 monthlater, the wounds appeared to be intact and there wasno evidence of further complication.

DISCUSSION

Overall the complication rate following laparoscopicsterilization is less than 1%8. The incidence of herniafollowing this procedure ranges from 0.02 to 0.6%.8,9

In these cases, the herniation of omentum or smallbowel occurred through port sites of 10 mm orgreater.10 The incidence of herniation through lateralport sites where 12-mm trocars have been used hasbeen quoted at 3% with poor muscle tone andincreasing age being risk factors.

Hernia or dehiscence at laparoscopic port sites israrely reported in the gynaecologic literature. In asurvey performed by the American Association ofGynecologic Laparoscopists, port-site herniae occurredwith an incidence of 21/100 000 laparoscopic proce-dures.2 Bowel herniation and vascular compromise iseven rarer, with only a few case reports entered in theliterature.

Of the herniae reported, 86% occurred in port sitesgreater than 10 mm in size, whilst only 2.7% occurredin port sites of less than 8 mm3,11 The most commonsite of herniation was through lateral port sites,followed by umbilical herniae. The morbidity asso-ciated with bowel herniation is significant, as 71% willrequire formal surgical repair and bowel resectionbecause of ischaemia.11

Risk factors for port-site herniae include the use oflarge ports, with 12-mm ports being 13 times more

likely to cause hernia than 10-mm ports, the use offascial fixation screws, laterally placed ports, poormuscle tone or entry through fascia and not muscle,elderly patients and failure to close fascial defects.10

Port-site closure, however, does not guarantee thatherniation will not occur, and it has been reported that17.9% of herniae occur despite closure of the fascia.10

Visceral herniation has never been reported after theuse of cyanacrylate tissue adhesives, nor through asmall suprapubic port site. The question of whetherthis is an appropriate technique for skin closure in portsites of greater than 5 mm is raised. It is recognisedthat large port sites should be formally closed, nomatter what their location, with an appropriate closuredevice, to prevent this rare but important complica-tion. It needs to be established whether the skinclosure is a factor in similar cases since, even though itis rare, a small elevation in the incidence may causesignificant avoidable morbidity.

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