Port site hernia (PSH), often referred to as port-site incisional hernia (PIH) or trocar site hernia (TSH), is characterized by the formation of a hernia at the sites of cannula insertion, with these names often used interchangeably in several publications. Published literature mentions the prevalence of PSH to be between 0.65% to 6.0%.¹ Numerous authors have acknowledged this as the inaugural report on trocar site hernias. Crist and Gadacz defined trocar site hernia as the occurrence of a hernia at the cannula insertion site.² Hitoshi et al. categorized trocar site hernias into three kinds based on documented instances.³ Early-onset type signifies dehiscence of the anterior fascial plane, posterior fascial plane, and peritoneum. The early-onset variant was identified in several case reports as commencing shortly after surgery, frequently manifesting as a small-bowel blockage. The late-onset type signifies dehiscence of the anterior and posterior fascial planes. The hernia sac of the late-onset kind is comprised of the peritoneum.

The late-onset form has frequently been associated, in several extensive studies, with problems arising after trocar implantation. Late-onset type hernias typically manifest in the latter phases, some months post-surgery.  Furthermore, the literature review indicated that almost all trocar site hernias occur at sites >10 mm, with only a limited number of instances documenting herniation at 5 mm sites.

We report a case of an Indian patient who developed late incisional hernia at the lateral 5 mm trocar insertion site that was produced during the elective Laparoscopic total abdominal hysterectomy for the treatment of symptomatic uterine fibroid.

CASE REPORT

A 63-year-old obese female patient with BMI 35 kg/m² presented to our centre with complaints of bulge in the left lateral abdominal wall that she had noticed first nearly 2 months back. It was known that the patient had undergone an elective laparoscopic Total Abdominal hysterectomy with Ipom for umbilical hernia through most lateral left 5 mm trocar port-site a year ago. Per-abdominal assessment led to finding of a palpable mass at the left lateral lumbar region, just above lateral 5 mm port-site scar. All haematological and biochemical parameters were within normal limits.

Plain CT scan of the abdomen was done that revealed a 3.1 cm sized defect in the anterior abdominal wall along the left lateral lumbar region with omentum and bowel loops as hernial contents. A diagnosis of trocar site incisional hernia (TSIH) was made, and the patient was planned for laparoscopic IPOM for the left lumbar hernia. Patient was placed in the supine position with a slight right tilt arms tucked by the side. Pneumoperitoneum was created using a Veress needle at the palmer’s point. Optical view entry using a 5mm optical trocar was done at the right hypochondrium, then a right iliac 5mm port and another 10mm port in the right lumbar region were placed under vision for instrumentation (figure 1). Adhesions were visualized over the previous mesh and adhesiolysis was performed. A defect in left lumbar region was seen, and it was approximated using absorbable barbed sutures in a continuous fashion. A 15x15 composite mesh was placed over the defect with a margin of 5 cm on either side. The defect was seen to be overlying on the previous mesh. Mesh was sutured using absorbable barbed sutures and inner crowning of the mesh was done using absorbable tacks. TAP block was given laparoscopically and proper haemostasis was achieved. 10mm port site was closed using a non-absorbable figure-of-8 stitch. Patient was shifted to ward, and she was managed with intravenous analgesics, antibiotics as well as antacids. Visual analogue scale (VAS) score for pain on post-operative day-1 was 3 out of 10. The patient recovered well after the procedure and was discharged in a hemodynamically stable state on post-operative day 2.

Figure 1: Port position- 5mm optical trocar at right hypochondrium, 10mm at right lumbar, 5mm at right iliac regions respectively.

Figure 2: Omental adhesions over the previous mesh

Figure 3: Defect in the left lumbar region

Figure 4: Defect closure with absorbable barbed continuous sutures

Figure 5: Mesh placement over the defect