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Laparoscopy is becoming the gold slandered of access to the abdomen and pelvis. However, it’s not without unique complications. Trocar site hernia is a rare but a serious complication which can cause diagnostic confusion, in the early post-operative period. It can be potentially life threatening with obstruction, strangulation, incarceration and finally perforation of the bowel, after a seemingly uncomplicated laparoscopy. First ever TSH, reported by “Fear in 1968”. Early studies described incidence from 0.002% to 5.2%. With improved surgical techniques & new closure methods, incidence has gone down significantly. Recent study, analyzing 55,244 cases reported it to be 0.016%. We discuss a case of small bowel herniation through the “12 mm lateral port”, even after aponeurotic closure with polyglactin. She presented with subacute bowel obstruction needing laparotomy. A diagnostic dilemma can arise in differentiating TSH, from “iatrogenic bowel perforation &peritonitis”. This article discusses how to minimize this serious complication, different port closure methods, suture materials, using currently available evidence and recommendations. USS may be less convincing particularly in obese. Diagnosis is commonly aided by plain X-ray film. CECT has significant advantages in differentiating TSH from incarcerated small bowel & ileus. RCOG advices closure of all 7 mm or larger lateral ports & 10 mm or larger midline ports. It can be prevented with proper pre-op evaluation, appropriate port selection, good specimen retrieval techniques, and use of proper closure methods & devices. Conventional J needle, laparoscopic suturing of the rectus sheath under direct vision, port closure devices, all have their own pros & cons. Specially designed port closure devices are encouraged wherever possible, especially in obese as well as patience with other risk factors. European hernia society recommends slowly absorbable monofilament sutures. Suture materials with higher tensile strength such as PDS in comparison to polyglactin may further improve outcome. *Corresponding author: Senadheera, De Soysa Hospital for Women, Colombo, Sri Lanka Check for updates

obstetrics and gynaecology cases - reviews

Trocar-Site Herniation (TSH) of the Small Bowel following Laparoscopy Despite Rectus Sheath Closure, Resulting in Subacute Bowel Obstruction in the Early Post-Operative Period: A Case Discussion and Review of Literature