Management of Port Site Hernia
Port site hernias should be managed surgically with a laparoscopic approach preferred in stable patients, while unstable patients or those with suspected bowel strangulation require open repair. 1
Initial Assessment and Diagnostic Approach
Abdominal CT (Option C) is the appropriate initial diagnostic step when port site hernia is suspected, particularly to assess for bowel incarceration or strangulation before determining the surgical approach. 2
Clinical presentation typically includes abdominal pain with a palpable mass at the previous trocar site, and may present as early postoperative small bowel obstruction. 3, 2
Port site hernias occur in approximately 0.14-1.23% of laparoscopic procedures, with 96% occurring at trocar sites of 10mm or larger diameter. 4, 5, 6
Surgical Management Algorithm
For Stable Patients Without Strangulation:
Laparoscopic repair (Option B) is the preferred approach in hemodynamically stable patients without evidence of bowel strangulation or necrosis. 1
The laparoscopic approach offers lower wound infection rates and acceptable recurrence rates compared to open repair. 1
This minimally invasive approach has an excellent safety profile with reported in-hospital mortality of 0.14%. 7
For Unstable Patients or Suspected Strangulation:
Laparotomy (Option A) is indicated when there is suspicion of bowel strangulation, necrosis, or hemodynamic instability. 1, 7
Open preperitoneal approach is preferable when bowel resection is anticipated. 1
Segmental bowel resection may be performed through a minimally extended port site incision if strangulation is confirmed. 2
Technical Repair Considerations
Repair technique depends on fascial defect size and patient risk factors:
Mean fascial defect size is typically 24-31mm, with mesh repair requiring significantly longer operative time (83 vs 40 minutes) but similar recurrence rates (9%) compared to suture-only repair. 4
Mesh should overlap the defect edge by 1.5-2.5cm when used. 7
Critical Clinical Pitfalls
Do not delay surgical intervention - all symptomatic port site hernias in this case series required surgical intervention, and early presentation can be associated with significant morbidity including bowel obstruction. 6
Consider port site hernia in any patient presenting with postoperative bowel obstruction after laparoscopic surgery, even at 5mm port sites in lengthy procedures where repetitive instrument motion may enlarge the defect. 3, 6
Hernioscopy (mixed laparoscopic-open technique) can be effective for evaluating bowel viability after spontaneous reduction, potentially avoiding unnecessary laparotomy. 1, 7