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Gynecology is the medical field which deals with the health of the female reproductive system. As all the other medical streams, the main tools of diagnosis are physical examination and clinical history. At the young age of 35 years I almost lost hope because of my disease, DIABETES, I was on insulin pump since .. PATIENT MEETING AND SEMINAR FOR DIABETES AND OBESITY SURGERY AT KUALA LUMPUR ON 16th AUGUST.
The surgery is therefore only performed after considering the other non-invasive and non-surgical treatments. Subtotal hysterectomy: The womb is removed, but the cervix is retained in such a kind of surgery. Radical hysterectomy: Along with the womb, surrounding parts like fallopian tubes, vaginal portions, lymph glands and ovaries are removed in this procedure.
Abdominal hysterectomy: In this method, the womb is removed by making an incision in the lower abdominal portion.
Vaginal hysterectomy: The top portion of the vagina is cut and the hysterectomy is performed.
Laparoscopic hysterectomy: This happens to be the most common method of performing hysterectomy. Welcome to the second installment of “The Hole in the Wall.” The purpose of this column is to provide the readers of Bariatric Times with a venue for an interactive exchange of ideas, interesting topics, and surgical pearls from experts in the field of abdominal wall defect repair as they relates to bariatric surgery. This column will review the literature to determine the clinical presentation, diagnosis, incidence, and outcome of port-site herniation and evaluate the evidence that supports closing port sites during bariatric laparoscopic operations. Unfortunately, the literature does not provide conclusive evidence to support selectively closing 12mm trocar sites and routinely closing 15mm trocar sites.
A PubMed search from 1985 to 2010 was performed using the search terms “trocar,” “port site,” and “hernia.” The search was restricted to articles in English and on human subjects.
His history of bowel obstruction prompted a CT scan of the abdomen and pelvis to rule of intra-abdominal or subcutaneous tissue abscess versus a trocar-site hernia.
Analyzing the 40 articles that met criteria for review, 16 articles specifically mentioned whether surgeons closed trocar sites. In the laparoscopic RYGB subpopulation, the incidence of trocar-site hernia was 1.1 percent.
Port-site hernias were reported in 124 patients: 26 uncomplicated, 14 complicated, and 84 with unknown outcomes.
Since the introduction of laparoscopic weight loss surgery, only 41 articles reported results of trocar-site herniation. In addition to trying to determine the incidence of trocar-site herniation, we questioned whether closing trocar-site fascia affects the trocar-site hernia rate or the incidence of complicated hernia. This study provides the most exhaustive search for trocar-site hernias in the published literature.
The weaknesses of our study and systematic literature reviews include the heterogeneity of operative technique, follow-up time variation without clear notation of exam for hernia, and type of studies that report trocar hernia rates. Our recommendation is to maintain high vigilance and suspicion when evaluating patients who have recently undergone laparoscopic weight loss surgery. In some countries, women should first consult a general practitioner or physician before approaching a gynecologist. Couple of reproductive parts like fallopian tubes, cervix and womb is removed in this surgery. In this method, the surgery is done by making several small incisions in the abdominal area.
There may be small risk for having a post-operative bleeding, bladder damage, infection etc.
We encourage your questions, ideas, and surgical scenarios in what we are certain will be an interesting and educational column.
Patients with morbid obesity who undergo laparoscopic surgery benefit from decreased post-surgical pain, shorter length of hospital stay, fewer wound-related complications, and fewer incisional hernias.[1] While the benefits of laparoscopy have been well characterized, the prevention, incidence, prevalence, and outcomes of incisional hernia at the working port sites are not commonly reported.
When considering the management of trocar sites in the patient with morbid obesity, the findings of thick omentum and short mesentery in this patient population should be considered to be protective from incarceration through small fascial defects. Thus, we reviewed our own experience and performed a systematic review of the current literature to define the incidence of trocar-site herniation among all patients undergoing laparoscopic bariatric surgery. All patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) at Cedars-Sinai Medical Center between January 1, 2009, and December 31, 2009, were identified using the Cedars-Sinai Medical Weight Loss Center of Excellence database. The bowel became immediately viable when released from the abdominal fascia, and a bowel resection was not required. The CT scan confirmed a high-grade small bowel obstruction, and the patient was explored laparoscopically (Figure 5).
Twenty-four authors did not mention how trocar sites were handled, but did report postoperative trocar-site hernia rates. Of the 26 uncomplicated hernias, two were observed and 24 were treated with incisional hernia repair (Figure 2). Surprisingly, we found that in the LRYGB patients, closure of trocar sites is associated with a significantly higher incidence of trocar-site herniation (1.1% vs. It became very clear to us that trocar site hernias are not easily searchable and are clearly under-reported. For example, not all authors reported details of the sizes and types of trocars that were utilized. The true incidence of trocar-site herniation may not be known until five years postoperatively, thus underestimating the incidence currently reported.[9] Furthermore, a complicated hernia usually presents as a surgical emergency, and it is possible that the original surgeon is uninvolved and unaware of this complication. The early signs of a complicated port-site hernia can be excessive pain, swelling at the site, and discoloration similar to a hematoma.


Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Hernia at 5-mm laparoscopic port site presenting as early postoperative small bowel obstruction. Direct visual insertion of primary trocar and avoidance of fascial closure with laparoscopic roux-en-y gastric bypass. Bands an bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Laparoscopic adjustable gastric banding in the treatment of obesity: A systematic literature review.
Comparison of five different abdominal access trocar systems: analysis of insertion force, removal force, and defect size. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: a comparative study of 1200 cases. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass.
Initial evaluation of laparoscopic Roux-en-Y gastric bypass and adjustable bypass and adjustable gastric banding in Korea: a single institution study. Two-year results on morbidity, weight loss and quality of life of sleeve gastrectomy as first procedure, sleeve gastrectomy after failure of gastric banding and gastric banding. Establishing laparoscopic Roux-en-Y gastric bypass: perioperative outcome and characteristics of the learning curve. Laparoscopic gastric bypass in patients 60 years and older: early postoperative morbidity and resolution of comorbidities. Early US outcomes of laparoscopic gastric bypass versus laparoscopic adjustable silicone gastric banding for morbid obesity. Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: a comparative study of 290 patients. Total stapled, total intral-abdominal (TSTI) laparoscopic Roux-en-Y gastric bypass: one leak in 1000 cases. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Prospective evaluation and 7-year follow-up of Swedish adjustable gastric banding in adults with extreme obesity.
Outcome and complications after laparoscopic Swedish adjustable gastric banding: 5-year results of a prospective clinical trial.
Five-millimeter trocar site small bowel eviscerations after gynecologic laparoscopic surgery. Samuel Szomstein for your interesting colunm and this month?s discussion theme, appreciating at the same time to the expert Dr. The term has derived from the Greek terms gyne and gynaika, which means the study of women.
Women experience many problems during her life span due to certain physical changes such as menstruation, pregnancy, menopausal etc. The gynecologist will study the women's organs such as uterus, ovaries, cervix, vagina, vulva, breasts and oviducts.
We are very honored to have Edward Phillips, MD, FACS, Director, Center for Minimally Invasive Surgery and Director of Endoscopic Surgery at Cedars-Sinai Medical Center, Los Angeles, California, as a guest expert. Case studies report poor outcomes from port-site herniation, particularly from bowel incarceration, including death.26 Whether to suture close a port site and which size port to close has not been elucidated. At the Cedars-Sinai Weight Loss Center of Excellence, Los Angeles, California, 12mm trocar sites are not routinely closed after gastric bypass, rather, they are closed selectively. The other purpose of this study was to identify the incidence of trocar site herniation based on whether the fascial defects are closed and to determine their outcomes. Case reports, technique papers, and articles on single-incision laparoscopy, natural orifice surgery, endoscopy, open surgery, and thoracoscopy were excluded. She had obesity-related comorbidities of hypertension, dyslipidemia, and a past medical history of seizures, hiatal hernia, and Crohn’s disease. The patient underwent LRYGB using five 12mm bladeless trocars, and the trocar sites were not closed.
At the time of surgery, strangulated small bowel and pus was noted in the lowermost left paramedian trocar site. After this incident, the patient was able to tolerate liquid diet and return to regular bowel function. The trocar configurations for both of these procedures are similar in that they require a similar number of trocars and at least a 15mm trocar, or a 12mm trocar fascial defect is widened in order to remove the stomach remnant or implant the adjustable gastric band device.
This is consistent with the incidence reported in the study by Lancaster[6] of 4,756 patients using ACS-NSQIP data (1.1% vs. The possible explanation of this finding is that LSG and LAGB requires a 15mm trocar and the fascia is widened to accommodate the stomach or the band. This is even among the population of patients with morbid obesity, who represent an ideal population to study outcomes as large databases exist and mandatory follow up is tightly regulated in bariatric Centers of Excellence. Initial experience with the adjustable gastric band in morbidly obese US adolescents and recommendations for further investigation. In order to rescue from those problems, it is necessary to give her special consideration and care.
Diseases or problems that affect these organs are infections, inflammations, tumors, injuries, congenital defects, benign, and hormonal variation issues. We welcome his expertise and comments in this month’s installment, “Working Port-Site Hernias: To Close or Not to Close?


For example, if a patient is found to have thin omentum, the surgeon may selectively close the 12mm trocar sites.
Patient charts were reviewed and only two documented trocar site hernias were identified and used for analysis. The initial literature search failed to identify many major known studies regarding the outcomes of the three most popular bariatric procedures—LRYGB, laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB).
Unfortunately, this patient’s postoperative course was complicated by heparin-induced thrombocytopenia, left upper extremity ischemia from pre-existing subclavian artery disease, and a mild cerebral vascular accident postoperatively. The patient followed an expected postoperative course and was able to tolerate a liquid diet prior to discharge on Postoperative Day 3. Thus, these two procedures were considered together as a single subpopulation to increase total numbers for better statistical power. One patient required small bowel resection, one required colonic repair, and one patient died of multi-organ system failure directly resulting from bowel strangulation (Figure 2).
This is in comparison to 12mm trocars placed in LRYGB where the fascia is not intentionally widened except when dilated to accomodate a circular stapler. A very important note, however, is that in our experience and, as shown in our systematic review, all complicated hernias occurred early postoperatively. Delay in diagnosis is common, requiring emergency surgery, bowel resection, and can result in death. My group perform LRYGB with two 5 mm and three 12 mm trocars without closing defects, and not having complications, but since we began to use umbilicus single port, only in those cases with cholecistectomy indication and besides in sleeve gastrectomy and resective LRYGB. The gynecologist also treats problems such as infertility issues, and menstruational disorders. Does It Matter in the Obese?” The Answers to the mesh test, which appeared in our first installment, are also available here. Data extracted included age, gender, body mass index (BMI), length of follow up, and surgical technique, including number and type of trocars placed and diameter of trocars used. A second literature search using the same limits and the search terms “laparoscopic” and “gastric bypass,” “sleeve gastrectomy,” “gastric band,” and “outcome” identified 952 articles (Figure 1).
Of note, he had a rather high narcotic requirement given his history of chronic pain syndrome. The fascial defect was closed with an 0-Vicryl, and the skin and subcutaneous tissue were managed with wet-to-dry dressings.
It could be that surgeons who close sites examine for the presence of hernia more assiduously or the technique of closure may contribute.
While this could be bias of follow up, our hospital is a large community teaching hospital and we have a bariatric surgery emergency service. We hope you enjoy our column, and we look forward to your questions, comments, and participation in future installments.
The patient followed an expected postoperative course until Postoperative Day 3 when she began to complain of abdominal pain unrelieved by narcotic medication.
He missed two of his postoperative appointments due to social reasons, and reported to his internist with complaints of cellulitis at his inferior, left, upper quadrant trocar site (Figure 4). All three complicated hernias (100%) occurred before Postoperative Day 30, whereas 5 of 6 uncomplicated hernias (87%) occurred after Postoperative Day 30. Fascial closure of trocar sites in patients with morbid obesity is often difficult and inadequate.  The inherent difficulty in placing transfascial stitches precisely with a suture passer can result in incomplete closure of the fascia or increase damage to already traumatized tissue. We operate on many bariatric patients from all over the region and have not operated emergently on another surgeon’s complicated trocar-site hernia. By this way, we already avoid to make a 15 mm right anterolateral wound for the green staple and its respective fascial closure. Of the 373 studies selected for review, 332 studies were excluded because they did not specifically mention port-site or incisional hernia in the body of the article.
On further questioning, he stated that he had not had flatus or bowel movements for 15 days. The implication is that complication from trocar-site hernia occurs early and the primary surgeon is usually involved.
Systematic review was performed on 41 articles: 27 on RYGB (1 randomized control trial, 2 prospective studies, 25 retrospective studies), 10 on LAGB (3 prospective studies, 7 retrospective studies), and 4 on LSG (4 retrospective studies). Data were mined for the number of port-site hernias, BMI, number, size and type of trocars used, whether trocar sites were closed, when hernias occurred, and associated morbidity and mortality of port-site hernias.
A computed tomography (CT) scan of the abdomen was obtained, which demonstrated a high-grade bowel obstruction secondary to a trocar-site hernia through the left anterolateral abdominal wall (Figure 3). It is unclear why this disparity exists; however, these meta-analyses are older studies, and more trocar-site hernias may have been reported over time or bladed trocars could have been used. Articles and authors were cross referenced to ensure that data points were not counted more than once. Also, there may be a greater appreciation of trocar-site hernias and their complications in patients with morbid obesity since outcomes reporting is required for Center of Excellence (COE) certification. A large American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) study by Lancaster[6] and two meta-analysis studies7,8 were eliminated from calculating the incidence of trocar-site hernia because of the potential for counting data points more than once. All corresponding authors of the 41 articles were contacted to provide additional information for this systematic review.



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