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HERBALS study: fascia closure does not protect against trocar hernias in multi-portal bariatric surgery

Thu, 06/18/2020 - 16:43
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A study investigating the prevalence and analysing the role of fascia closure in the development of trocar hernias has reported that trocar site hernias are an underestimated complication of minimally invasive, multi-portal bariatric surgery, and the prevalence of asymptomatic hernias is probably higher than initially expected. The study also found that fascia closure did not protect against trocar hernias.

The study, ‘Trocar Site HERnias After Bariatric Laparoscopic Surgery (HERBALS): a Prospective Cohort Study’, published in Obesity Surgery, by researchers from Heidelberg University, Mannheim, German, noted that the exact prevalence of trocar site hernias after bariatric procedures is not yet known with differing research in the literature estimating the prevalence rate of 15-40% (Karampinis I, Lion E, Grilli M, et al. Trocar site hernias in bariatric surgery-an underestimated issue: a qualitative systematic review and meta-analysis. Obes Surg. 2019 Jan;18 and Scozzari G, Zanini M, Cravero F, Passera R, Rebecchi F, Morino M. High prevalence of trocar site hernia after laparoscopic or robotic Roux-en-Y gastric bypass. Surg Endosc 2014 Oct;28(10):2890–2898). Subsequently, the researchers designed a study to ascertain the prevalence of trocar site hernias after bariatric procedures and whether role of fascia closure could influence the development of trocar site hernias.

The researchers included adult patients who had a bariatric surgery at the Department of Surgery, Universitätsmedizin Mann heim, Medical Faculty Mannheim, Heidelberg University, between 2009 and 2018. Exclusion criteria included the following: laparoscopic surgery in the upper abdomen before the bariatric procedure, any type of midline or transverse laparotomy in the upper abdomen before or after the bariatric procedure, and procedures implementing implantable devices penetrating the fascial layer.

They analysed the effect of fascia closure in the entire cohort by dividing the patients into two groups based on whether or not the fascia had been sutured during the bariatric operation. In order to define the absolute prevalence of trocar site hernias and the role of fascia closure in the development of trocar site hernias, they then repeated the statistical analysis including patients who had only had a single bariatric operation.

Outcomes

In total, 359 patients (331 primary procedures and 28 revision cases) were available for analysis in the study and the overall follow-up rate was 56%. Trocar site hernia was identified in 124 patients (total prevalence 34.5%) and a total of 146 trocar site hernias were diagnosed in all 1,795 trocar sites (8.13%). Although the patients’ characteristics did not differ significantly between the group who had received a fascia closure and the group where the fascia had not been closed, the length of surgery, hospital stay and follow-up were significantly different in the fascia closure group of patients.

The analysis of 5mm trocars site hernias were identified in 18 patients (overall hernia prevalence was 2.5%) that were not closed because of the very low prevalence of hernias in trocar sites smaller than 10mm. The analysis of 12mm trocars site hernias (excluding those that had been widened to enable the extraction of the resected stomach) identified 961 trocar sites and 102 trocar hernias (10.6%) (Figure 1).

Sonography scan showing a trocar site hernia (left) and a further hernia with omental fat incarceration (right)
Sonography scan showing a trocar site hernia (left) and a further hernia with omental fat incarceration (right)
 

The researchers analysed trocar sites that were used for the extraction of the resected stomach after sleeve gastrectomy separately. Twenty-six trocar site hernias were detected in 116 locations (22.4%). The fascial layer was always closed in this trocar site and no significant difference in the number of trocar site hernias between the fascia closure group and the no fascia closure group. No significant difference was detected (p=0.23) in the group of patients with fascia closure (14 trocar site hernias, 38.8%), compared to the group without fascia closure (35 trocar site hernias, 28.4%).

In a multivariate analysis to detect potential risk factors associated with the development of trocar site hernias, the researcher reported that age, gender, BMI at surgery, BMI at follow-up, type of surgery, diabetes, smoking history, ASA score, abdominoplasty reconstruction, length of surgery, surgeon and length of hospital stay were not associated with a higher risk for trocar site hernias. However, excessive weight loss was associated with a higher risk for trocar site hernias (p = 0.05).

“Both our earlier meta-analysis and this current study failed to demonstrate a difference in the prevalence of trocar site hernias between patients where the fascia was closed and in patients where the fascia was not closed,” the authors concluded. “However, opposing evidence from similar trials suggests closing the fascia. This clinical problem should therefore be further assessed in a prospective randomised setting.”

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