What is the risk of umbilical hernia in adult patients with symptomatic gallstones undergoing single incision cholecystectomy (SIC)?

Umbilical Hernia Risk After Single-Incision Cholecystectomy

Single-incision laparoscopic cholecystectomy (SILC) carries a substantially higher risk of incisional hernia compared to conventional multiport laparoscopy, and should be avoided in favor of traditional laparoscopic approaches for patients with symptomatic gallstones. 1

Primary Recommendation

• Conventional multiport laparoscopic cholecystectomy is strongly recommended over SILC due to the significantly elevated incisional hernia risk associated with the single-incision technique 1
• The 2023 World Society of Emergency Surgery guidelines provide strong evidence (Grade 1B) against routine use of SILC, citing higher hernia rates as the primary concern 1

Quantified Hernia Risk

Overall Incidence

• SILC is associated with an incisional hernia rate of 5.5% to 6.35% in recent studies, which is substantially higher than the 0.1-1.0% rate seen with traditional multiport laparoscopy 2, 3
• The majority (67%) of incisional hernias after SILC are diagnosed within the first year of follow-up 2
• In contrast, traditional laparoscopic cholecystectomy has an overall incisional hernia rate of only 1.8%, with most occurring at the umbilical port site 4

Comparative Risk

• Meta-analysis shows no statistically significant difference in hernia rates between SILC (2.96%) and multiport laparoscopic cholecystectomy (4.4%), though this finding is limited by high heterogeneity between studies 5
• However, guideline-level evidence consistently demonstrates increased hernia risk with SILC, leading to the strong recommendation against its routine use 1

High-Risk Patient Populations

Body Mass Index

• Obesity (BMI >30 kg/m²) increases incisional hernia risk 2.65-fold after minimally invasive cholecystectomy 5
• Morbidly obese patients have the highest incidence at 18.18% following SILC 3
• Each unit increase in BMI confers a hazard ratio of 1.30 for developing incisional hernia 2

Age

• Older age is an independent risk factor, with patients developing hernias being on average 9.6 years older than those who do not 5
• Age shows statistical significance in both univariate and multivariate analyses for SILC procedures 3

Pre-existing Umbilical Defects

• Pre-existing umbilical or paraumbilical hernias occur in 12% of patients undergoing laparoscopic cholecystectomy, though most patients are unaware of these defects 4
• Previous umbilical hernia is a significant independent risk factor (p=0.00212) for developing port-site hernias after SILC 3
• However, one analysis found no increased risk with prior umbilical hernia repair (RR 2.12; 95% CI 0.86-5.22; p=0.1), though this may reflect successful repair technique 5

Metabolic Factors

• Diabetes mellitus doubles the risk of incisional hernia (RR 2.15) after minimally invasive cholecystectomy 5
• Male sex is associated with higher hernia rates in traditional laparoscopy but shows no significant association in SILC-specific analyses 4, 5

Perioperative Complications

• Surgical site infection increases hernia risk 5.3-fold (RR 5.3; 95% CI 3-9.1) and shows the strongest association among all risk factors 5
• Wound infection after SILC confers a hazard ratio of 26.32 for developing incisional hernia 2
• Wound extension during traditional laparoscopy is associated with increased hernia risk, occurring in 75% of hernia cases 4
• Acute cholecystitis shows a trend toward increased risk (RR 2.6) but does not reach statistical significance 5

Risk Mitigation Strategies

If SILC Must Be Performed

• Meticulous fascial closure is mandatory when SILC is performed, though this recommendation carries only weak evidence (Grade 2C) 1
• Non-absorbable sutures should be used for fascial defects larger than 2 cm, particularly in male patients 4
• Mesh-based repair shows superior outcomes compared to primary suture techniques, with 0% recurrence versus 9.4% recurrence with primary suture in patients with pre-existing umbilical hernias 6

Surgical Technique Considerations

• The learning curve matters: CUSUM analysis demonstrates decreased hernia risk after the first 10 SILC cases, suggesting technical proficiency reduces complications 2
• Avoid unnecessary wound extension, which occurred in 75% of patients who developed incisional hernias after traditional laparoscopy 4
• Pre-existing umbilical defects should be identified preoperatively and repaired anatomically using absorbable sutures in 90% of cases 4

Critical Clinical Algorithm

For patients with symptomatic gallstones requiring cholecystectomy:

1. Default to conventional multiport laparoscopic cholecystectomy 1

2. If SILC is being considered, assess risk factors:

   • BMI >30 kg/m²? → Strongly favor multiport approach 5, 2, 3
   • Diabetes mellitus present? → Strongly favor multiport approach 5
   • Pre-existing umbilical hernia? → Strongly favor multiport approach 3
   • Age >65 years? → Consider multiport approach 5

3. If SILC proceeds despite risk factors:

   • Use non-absorbable sutures for fascial closure 4
   • Consider prophylactic mesh reinforcement in high-risk patients (BMI >30, male sex, diabetes) 6
   • Ensure meticulous fascial closure technique 1
   • Implement aggressive wound infection prevention protocols 5, 2

Common Pitfalls to Avoid

• Do not assume SILC is equivalent to multiport laparoscopy in terms of hernia risk—guideline-level evidence clearly demonstrates increased complications 1
• Do not use absorbable sutures for large fascial defects (>2 cm) or in male patients, as this increases recurrence rates 4
• Do not overlook pre-existing umbilical defects, which occur in 12% of patients and are often asymptomatic 4
• Do not underestimate the impact of surgical site infection, which increases hernia risk more than 5-fold and should be aggressively prevented 5, 2
• Do not perform SILC during the learning curve in high-risk patients, as technical proficiency significantly impacts outcomes 2