Port Site Hernia

Port site hernia is a late structural complication of laparoscopic and robotic surgery, in which a defect in the abdominal wall fascia at an access site enlarges over months to years and allows omentum or bowel to protrude. Overall incidence is about 1 to 2%, and most are at the umbilical or extraction site. Rates are higher after single-incision surgery (up to 10%), after robotic surgery with large assistant ports, and after bariatric operations.

Anatomy and pathology

• The midline umbilical and epigastric sites lack muscle cover and heal poorly.
• Lateral port sites contain oblique muscle fibers, so defects are smaller and rarer.
• Hernias may be small (under 2 cm) or large (over 4 cm), and some are multiple.
• Weakness of the closure, seroma, infection and increased pressure widen the defect.

Contents are omentum in most, then small bowel, and rarely colon or bladder. The risk of incarceration is lower than for other abdominal wall hernias with larger defects, but is not zero. Complications: incarceration, strangulation, chronic pain, skin changes and recurrence after repair.

• A painless or mildly painful bulge at a previous port, which enlarges on standing, coughing or lifting
• Local discomfort, dragging pain and cosmetic concern
• A reducible lump with a palpable fascial defect and a cough impulse
• Obstructive symptoms in incarceration, with a tender irreducible mass
• Red flags: acute pain, vomiting, a hard tender lump, skin discoloration and fever

1. Clinical examination with the patient standing and supine, including tests with the head raised from the pillow to tense the abdominal wall.
2. Ultrasound of the abdominal wall, with dynamic scanning on Valsalva, to show defect size and contents.
3. CT of the abdomen to define multiple defects, the contents, adjacent hernias and the muscle condition. It is needed when the clinical diagnosis is uncertain or the patient is obese.
4. Optimization tests: HbA1c, full blood count and creatinine before elective repair.

Differentials: seroma, lipoma, abscess, desmoid tumor, port site metastasis, rectus diastasis, endometriosis in the abdominal wall.

1. Asymptomatic small hernias: watchful waiting is acceptable, with advice on weight loss, smoking cessation and glycemic control (HbA1c under 8% before elective repair, BMI under 35 where possible).
2. Elective repair for symptoms, enlarging defects and defects over 1 cm:
   • Open primary suture closure of the defect for defects under 1 to 2 cm with a non-absorbable 0 suture.
   • Mesh repair for defects over 2 cm: open sublay (retromuscular) or laparoscopic intraperitoneal onlay mesh with an overlap of at least 5 cm beyond the defect and fixation by tacks or sutures.
   • Use a coated or composite mesh when placed intraperitoneally.
   • Excise the sac and inspect the bowel.
3. Prophylaxis: cefazolin 2 g IV 30 to 60 minutes before incision (3 g if over 120 kg), and enoxaparin 40 mg SC once daily for 7 days in higher-risk patients.
4. Emergency presentation with incarceration: resuscitation with IV crystalloid 20 mL/kg initially, nasogastric decompression if obstructed, cefazolin 2 g IV with metronidazole 500 mg IV, urgent exploration, bowel resection if non-viable and primary repair (mesh only if the field is clean).
5. Postoperative care: paracetamol 1 g orally every 6 hours, avoidance of lifting over 5 kg for 4 to 6 weeks, and abdominal binder as tolerated.
6. Outcomes and complications: recurrence 2 to 10% (higher with suture repair alone), seroma, mesh infection (1 to 3%), chronic pain, hematoma and enterotomy.

Follow-up at 2 and 6 weeks and 12 months. Counsel on weight control and on avoiding straining.