Management of Port Site Hernia After Laparoscopic Cholecystectomy
Surgical repair is strongly recommended for port site hernias after laparoscopic cholecystectomy, with meticulous fascial closure to decrease the risk of recurrence. 1
Incidence and Risk Factors
Port site hernias (PSH) are a rare but potentially serious complication of laparoscopic cholecystectomy with an overall incidence of approximately 1.7% (range 0.3-5.4%) 2. These hernias occur more frequently at:
- Larger port sites (≥10 mm)
- Midline port sites
- Sites extended for gallbladder extraction
Key risk factors include:
- Older age
- Higher body mass index (BMI)
- Preexisting hernias
- Trocar design (bladed trocars have higher risk)
- Increased duration of surgery
- Wound infection
- Male sex
- Diabetes mellitus 2, 3
Diagnosis
Port site hernias typically present with:
- Palpable mass at the port site
- Pain or discomfort at the port site
- Signs of intestinal obstruction in complicated cases (nausea, vomiting, abdominal distension)
- Incarceration or strangulation may occur in acute presentations 4
Diagnosis is primarily clinical, but imaging may be required in unclear cases:
- Abdominal ultrasonography for initial assessment
- CT scan for complicated cases or when diagnosis is uncertain
Management Algorithm
1. Uncomplicated Port Site Hernia
- Surgical repair is the definitive treatment
- Primary fascial closure with non-absorbable sutures for small defects
- Mesh repair for larger defects (>2 cm) or recurrent hernias
- Laparoscopic or open approach depending on surgeon expertise and patient factors
2. Complicated Port Site Hernia (with obstruction/strangulation)
- Emergency surgical intervention
- Release of incarcerated contents
- Resection of non-viable tissue if present
- Primary fascial closure or mesh repair depending on contamination and defect size
- Broad-spectrum antibiotics if bowel compromise is present
Surgical Technique
The World Society of Emergency Surgery (WSES) recommends:
- Complete reduction of hernia contents
- Careful assessment of bowel viability
- Meticulous fascial closure with non-absorbable sutures
- Consider mesh reinforcement for larger defects or in patients with risk factors for recurrence 1
Prevention Strategies
The WSES strongly recommends:
- Closure of fascial defects for all port sites ≥10 mm 1
- Consider fascial closure even for 5 mm ports in high-risk patients
- Use of non-bladed trocars when possible
- Careful port removal under direct visualization to prevent bowel entrapment
- Minimize port site extension for specimen extraction
Although some studies suggest that unclosed fascial defects may not significantly increase PSH risk 5, the consensus from guidelines supports fascial closure, especially for larger port sites, to minimize hernia development.
Post-Repair Care
- Early mobilization
- Avoidance of heavy lifting for 4-6 weeks
- Monitor for signs of recurrence or infection
- Consider abdominal binder for obese patients
Special Considerations
For patients with multiple risk factors (obesity, diabetes, prior hernias), consider:
- Prophylactic mesh placement during repair
- Extended period of activity restriction
- Closer follow-up to monitor for recurrence
Port site hernias represent a significant complication that can lead to serious morbidity if not properly managed. Early recognition and appropriate surgical repair are essential to prevent complications such as bowel obstruction, incarceration, and strangulation.