Port site closure

Port site herniation is a postoperative complication that may lead to small bowel strangulation or incarceration, often requiring

emergency intervention and has resulted in deaths when unrecognized (86).

The incidence of port site herniation following gynaecological laparoscopy is low and reported to be 0.06-1%, with a size of more than 7 mm and extraumbilical location of ports (particularly lateral) important for subsequent hernia development (87). The risk factors for port site herniation include previous history of port site hernia, postoperative wound infection, poor wound healing, ascites, obesity, connective tissue disorder, and extensive port manipulation (88). Fascial closure should be performed in patients with these risk factors regardless of the port size (63). Closure of a port size less than 5 mm in diameter is generally not required because hernia formation is rare, but it has been reported in the literature. For port sites of at least 7 mm, fascial closure is recommended to reduce the risk of this complication (89, 90). The majority of port site herniation occurs at ports of at least 10 mm although fascial defects of up to 12 mm using the tissue separating plastic trocars may not be at lower risk of this issue (63). It would, however, seem prudent to close the fascia wherever possible.

Table 47.3 Randomized controlled trials comparing modes of intraoperative analgesia

bgcolor=white>Postoperative pain

First author and year	No. of patients	Mode of analgesia	Principal outcomes	Comments
Benhamou 1994 (69)	25	Intraperitoneal and mesosalpinx local anaesthetic vs placebo	Postoperative pain, analgesia requirement, time to return to normal activities	Less postoperative pain, analgesia requirement and time to return to normal activities in multimodal group
Michaloliakou 1996 (70)	49	Multimodal (port site injection, intramuscular) vs placebo	Postoperative pain, nausea, and readiness for discharge	Significantly less postoperative pain and nausea, faster discharge
Einarsson 2004 (71)	82	Port site injection pre operation vs post operation	Less postoperative pain within 1 hour with postoperative infiltration group
Grube 2004 (72)	163	Port site injection pre operation vs placebo	Postoperative pain, analgesia, functional limitation,	No significant difference
Lam 2004 (73)	144	Port site injection pre operation vs post operation vs placebo	Postoperative pain, predischarge analgesia, total analgesia	Less pain in preoperative infiltration group.
Chou 2005 (74)	91	Intraperitoneal instillation postoperatively vs both preoperatively and postoperatively vs placebo	Shoulder tip pain, abdominal visceral pain, abdominal parietal pain, length of stay, postoperative analgesia consumption, side effects	Significant reduction of abdominal visceral pain within 8 hours post operation in preoperative and postoperative instillation of bupivacaine. No significant difference in length of stay
Ghezzi 2005 (75)	170	Preoperative port site injection vs placebo	Postoperative pain and analgesia, time to first analgesic request	No significant difference
Jabbour 2005 (76)	100	Multimodal (intraperitoneal spray, intravenous) vs placebo	Postoperative pain, nausea, vomiting	Significantly reduced postoperative pain and vomiting in multimodal group
Kim 2005 (77)	83	Multimodal (port site injection, intramuscular), vs placebo	Postoperative pain, first analgesia request time	Significantly reduced postoperative time and longer first analgesia request time in multimodal group
Louizos 2005 (78)	214	Port site and intraperitoneal injection vs placebo	Postoperative pain, analgesia, patient satisfaction	Less pain, less analgesia, more patient satisfaction in treatment group
Alessandri 2006 (79)	74	Port site injection vs placebo	Postoperative pain and analgesia time to ambulation, length of stay	Less postoperative pain, analgesia and mobilization. No significant difference in length of stay.
Costello 2010 (67)	66	Multimodal (suppository, port site, intraperitoneal and sub-diaphragmatic local anaesthetic) vs placebo	Postoperative pain, postoperative opioid requirement, nausea, vomiting, sedation, length of stay	Less opioid requirement in multimodal group. No significant difference in other outcomes
Kane 2012 (80)	58	Transversus abdominis plane block post operation vs placebo	Postoperative pain, total analgesia requirement, operating time	Less operating time in treatment group. No other significant differences
Kwon 2012 (81)	40	Topical local anaesthetic vs placebo	Postoperative pain, analgesia requirement, nausea and vomiting, length of stay	Less pain in treatment group. No other significant differences
Manjunath 2012 (82)	196	Intraperitoneal local anaesthetic vs placebo	Postoperative pain, analgesia requirement nausea	Less pain and nausea in treatment group. No significant difference in analgesia requirement
Arden 2013 (83)	157	Intraperitoneal local anaesthetic vs placebo	Postoperative pain, opioid requirement, length of stay, patient satisfaction	No significant differences
Tam 2014 (84)	135	Port site local anaesthetic vs placebo	Postoperative pain	No significant difference
Hotujec 2015 (85)	64	Transversus abdominis block pre operation vs placebo	Postoperative pain, analgesia	No significant difference

Fascial closure is the key feature for reducing this complication and the exact technique by which this is achieved is largely up to the surgeon with no clear superiority of one technique or tool over any other (91). Skin closure may be by suture, tissue adhesive with 2-octylcyanoacrylate (Dermabond), and microporous tapes. These latter two options are suggested to approximate superficial wound edges with less tension and maintain the integrity of epidermis, resulting in better cosmesis and fewer early complications such as wound erythema, tenderness, and drainage when compared to suture closure (91, 92).

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Source: Arulkumaran S., Ledger W., Denny L., Doumouchtsis S. (eds.). Oxford Textbook of Obstetrics and Gynaecology. Oxford University Press,2020. — 928 p.. 2020

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Port site closure

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