|LETTER TO THE EDITOR
|Year : 2012 | Volume
| Issue : 3 | Page : 191-192
Omental herniation through trocar site
Ashwini R Gadekar, Meena N Satia, Jayant S Rege, Sandeep Hambarde
Department of Obstetrics and Gynecology, Seth GSMC, KEM Hospital, Mumbai, India
|Date of Web Publication||5-Jun-2012|
Ashwini R Gadekar
c/o. Prof. R.B. Hambarde, Hambardegalli, Ashti. Dist. Beed - 414 203, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gadekar AR, Satia MN, Rege JS, Hambarde S. Omental herniation through trocar site. Ann Afr Med 2012;11:191-2
The role of diagnostic and therapeutic laparoscopy in gynecology has expanded in recent years. Diagnostic laparoscopy, an excellent and safe technique to establish an accurate diagnosis of various disorders, is associated with a low incidence of major intraoperative complications. The increasing use of laparoscopic surgery in management of gynecological diseases resulted in an increasing incidence of complications and development of new complications like bladder, urachal diverticulum and ureteric injuries, gastrointestinal tract or electrosurgical injuries. A rate of 2.76 per 1,000 for complications requiring laparotomy and a mortality rate of 0.13 per 1,000 has been reported.  The likelihood of laparotomy being required is directly related to the degree of procedure with a rate of 0.42 per 1,000 for minor and 4.46 per 1,000 for major laparoscopic surgery. 
Post-operative complications are uncommon after laparoscopy. The most common complication is incisional herniation most likely occurring when large ports are used. Trocar site herniation is a rare but potentially serious complication of laparoscopic surgery. Complications can range from small omental herniations, requiring minor surgery to delayed hernia formation or even bowel entrapment. Bowel herniation has the potential to be further complicated by incarceration, strangulation and devitalization. In these cases, major surgical intervention is needed with the risk of significant morbidity and even mortality. This report describes a case of omental herniation through a 10-mm supraumblical incision following uneventful laparoscopic tubal ligation.
A 28-year-old woman, having two living issues, referred to us on post-op day 7 of laparoscopic tubal ligation in view of swelling arising through supraumblical trocar site detected when she came for suture removal. When presented to us, her vitals were stable. She did not appear to have any discomfort and on local examination about 3-cm pinkish mass was coming out through supraumblical trocar site, without any discharge and an otherwise benign abdominal examination. According to details available, she underwent laparoscopic tubal ligation through supraumblical 10-mm trocar insertion. There were no intraoperaive complications. Patient was discharged in good condition on 3 rd post-operative day. When she came for suture removal, swelling was detected and she was referred to us.
CT scan of abdomen was done and origin of mass as omental herniation through trocar incision was confirmed. She was taken to operative room and excision of necrotic omental tissue and closure of fascia and skin was performed. Post-operative course of this surgical intervention was uneventful.
Omental prolapsed after laparoscopy is a rare complication with a reported prevalence of 0.02%.  The use of large size trocars and increasing frequency of more aggressive laparoscopic procedures causes a rise in port-associated complications. There are only two reports discussing etiology of omental prolapsed through port incision after laparoscopy. , Howard and Sweeney  suspected that copious exit of irrigation fluid, left in the abdominopelvic cavity, actually flushed the omentum through umbilicus. Bishop and Halpin  has described episode of intractibal coughing on 4 th post-operative day as a cause of herniation.
Fascial closure thought to be an appropriate method to avoid herniation. However, Kadar et al.,  reporting on a series of 5,560 operative laparoscopies, noted that in three of five hernias involving 12-mm trocar fascial closure had performed.  Since herniation is unlikely after adequate fascial closure, when it occurs, it supposed to be due to fascial sutures which are often only subcutaneous sutures. In 1995 Montz  suggested that adequate closure of defect can be guaranteed by placing fascial sutures under direct laparoscopic view at all sleeve locales' moving the laparoscope from umbilical trocar to the port in lower abdomen to enable vision of suture placement .Another approach to avoid incisional herniation was reported by Semm  who described the transumblical Z-incision technique. However, there are no data from controlled trials available on this issue and prospective studies are unlikely to be performed because of the low prevalence of this complication and high number of cases necessary.
Since the herniation through trocar incision might implicate severe complications, Usage of safety techniques for fascial closure such as method described by Montz  or the placing of ports via the Z-incision technique should be applied routinely to reduce laparoscopy-associated morbidity.
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