IMMEDIATE POSTOPERATIVE ROBOTIC PORT SITE HERNIAS: MOUNTAIN OR MOLEHILL?
Tanuja Damani, Les James*, Jason C. Fisher, Paresh Shah
New York University Langone Medical Center, New York, NY
Introduction: Fascial closure at 8 mm robotic port sites continues to be controversial. As the use of robotic platform increases across multiple abdominal specialties, there are more case reports describing reoperation and small bowel resection for acute port site hernias. Our hypothesis was that the incidence of this complication is very low, and we sought to identify potential predisposing factors for robotic port site hernias.
Methods: A retrospective review of all robotic abdominal surgeries, inclusive of gynecology, urology and general surgery (including colorectal surgery), performed from January 3, 2012 to October 31, 2019, at NYU Langone Medical Center, was conducted. Patients who had a reoperation in our facility within 30 days were identified, and medical records reviewed for indications for reoperation and findings.
Results: The study included 11,566 patients. Seventeen patients required reoperation within 30 days for incisional and port site hernias. Two of these hernias were at mini-laparotomy incisions, and were excluded from review. Fifteen of 11,566 patients (0.129%) had acute port site hernias, and 3 of these 15 patients required small bowel resection. Incidence of port site hernias by specialty was 0.290% for general surgery, 0.123% for gynecology, and 0.081% for urology. The mean age of the patients was 65.3 years (range 44-85) and mean BMI was 26.8 (range 20.4-39.5). Reoperation was performed at a median of 4 days after the initial surgery, with 80% reoperated within the first 7 days (range 2-22). Eleven of 15 acute port site hernias (73.3%) were at 8 mm robotic port site, 2 of which required a small bowel resection. Ten of 11 hernias were at lateral port sites, with one being periumbilical. More than a third of the patients (4/11) had a hernia at a site where a surgical drain had been placed. Two of these patients had incarcerated omentum noted at the port site as the drain was pulled at discharge, but no incarcerated small bowel noted at time of reoperation. The remaining 2 patients presented after discharge with incarcerated small bowel at a prior drain site. Assuming that each robotic case had four 8 mm port sites, the true incidence of immediate postoperative robotic port hernia was 0.0238 % (11/46,264), and those requiring small bowel resection was 0.004% (2/46,264).
Conclusion: To our knowledge, this is the largest study to date looking at immediate postoperative robotic port site hernias across multiple specialties. The incidence of acute port site hernias from 8 mm robotic ports is exceedingly low across specialties. There does not appear to be a procedure specific risk. The majority of these occur within the first week after surgery. Our results do not support routine fascial closure at 8 mm robotic port sites due to an extremely low incidence. However, drain sites require special consideration.
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