Articles

Prevention and Management of Complications in Urological Laparoscopic Port Site Placement

By: Richard J. Pemberton a, David A. Tolley b lowast , Rol and F. van Velthoven c

Published online: 01 November 2006

Keywords: Laparoscopy, Port site, Complications, Access

Abstract Full Text Full Text PDF (563 KB)

Abstract

Objectives

To review complications associated with urological laparoscopic port-site placement and outline techniques for their prevention and management.

Methods

Review of the literature using Medline.

Results

Laparoscopy now plays a key role in urological surgery. Its applications are expanding with experience and evolving data confirming equivalent long-term outcome. Although significant port-site complications are uncommon, their occurrence impacts significantly on perioperative morbidity and rate of recovery. The incidence of such complications is inversely related to surgeon experience. Ports now utilise bladeless tips to reduce the incidence of vascular and visceral injuries, and subsequently port-site herniation. Metastases occurring at the port site are preventable by adhering to certain measures.

Conclusions

Whether performing standard or robot-assisted laparoscopy, port-site creation and maintenance is critical in ensuring minimal invasiveness in laparoscopic urological surgery. Although patient factors can be optimised perioperatively and port design continues to improve, it is clear that adequate training is central in the prevention, early recognition, and treatment of complications related to laparoscopic access.

Take Home Message

A wide range of potential complications can occur with placement of laparoscopic ports, with significant impact on perioperative morbidity and convalescence. Urologists should be trained not only in laparoscopic procedures but, importantly, in the prevention and management of such complications.

Keywords: Laparoscopy, Port site, Complications, Access.

1. Introduction

Laparoscopic surgery is now a well-accepted component of urological practice. An ever-increasing number of urological operations are being performed by a less-invasive laparoscopic approach. Large prospective studies from established centres confirm significantly shorter postoperative convalescence while maintaining outcome and long-term oncologic control (upper renal tract surgery at time of review) [1]. A vital component of safe effective laparoscopy is the ability to insert, secure, and maintain access ports in an optimal location while avoiding injury to surrounding structures.

Although complications associated with port-site placement are uncommon in experienced hands, the potential for associated morbidity is high. Urologists performing laparoscopic surgery must therefore have the knowledge and necessary skill to prevent, recognise, and manage complications related to port-site placement. Obviously the best method to manage port-site complications is to prevent their initial occurrence, and the optimal time to repair an injury is at the time of its creation.

2. Methods

The Medline search was conducted by using the keywords laparoscopy, port-site complications, and laparoscopic access. Suitable papers published in English between 1985 and 2006 were included in writing this review.

3. Port insertion technique

There are three main options for initial port insertion: open Hasson technique, closed access using the Verres needle, or use of an optical port. The site of insertion depends on the procedure and whether the site is approached trans- or retroperitoneally. To avoid the epigastric vessels, the site is generally located lateral to the rectus abdominus or just below the tip of the 12th rib, respectively, in upper renal tract laparoscopy. In pelvic laparoscopy, the site is para- or infraumbilical according to the type of approach.

The primary camera port is generally in line with the structure of interest and approaches it at a 45° angle, allowing triangulation of at least two secondary working ports that are inserted under vision [2]. The size of the skin incision should allow insertion without undue pressure while not being large enough to create an air leak around the port (i.e., similar to port size or two thirds the size in radially dilating ports). The trocars are inserted by a firm constant screwing motion.

In robotic urological laparoscopy, the ports are all inserted as in standard laparoscopy prior to insertion of the robotic arms. Two 8-mm port sites are used for the robotic arms and two 12-mm ports for the camera and passage of suture needles/clip applicators. The inherent risk of insertion of these ports does not differ from standard laparoscopy [3].

3.1. Open access using the Hasson technique

Many centres including the authors favour the Hasson technique [4]. A 1.5-cm to 2-cm skin incision is made, followed by sharp and blunt dissection to visualise the external fascia. The fascia is incised and muscle layers are split, revealing the transversalis fascia and peritoneum, which are grasped with haemostats and opened sharply. A finger is then inserted to confirm presence within the peritoneal cavity. The Hasson blunt tip cannula is then inserted and secured in position by fascial stay sutures, aiming to avoid any gas leak. A blunt tip balloon cannula can also be used.

Retroperitoneal renal access also typically uses this technique. The correct position is confirmed by palpating the psoas posteriorly and the lower pole of the kidney superiorly. A space is then created, usually with a dilating balloon under vision (up to 800ml) with subsequent insertion of the primary port. Proponents of this approach often favour a balloon port to minimise air leak [5].

3.2. Closed access using the Verres needle

This procedure involves blind insertion of the Verres needle to create a pneumoperitoneum. The needle design allows tactile feedback as it passes through various layers of the abdominal wall. After initial aspiration to exclude blood or bowel content, various tests confirm the needle's intraperitoneal position (e.g., saline drop) prior to CO2 insufflation. The intraperitoneal pressure should be initially low at low flow (1l/min). Intra-abdominal pressure is then initially set at 15–20mm Hg for primary port insertion, which is done via dilating an expandable sheath initially around the needle (Fig. 1) or inserting a separate port-site system (Fig. 2).

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Fig. 1

Autosuture radially expanding Versastep port system.

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Fig. 2

Five different 12-mm trocar systems. (A) Ethicon cutting. (B) Autosuture Versastep. (C) Ethicon conical tip. (D) Applied cutting. (E) Applied separator.

For pelvic laparoscopy, the needle is inserted subumbilically directed towards the pelvis, while the patient is in the Trendeleburg position with the bladder empty. In upper-tract laparoscopy with the patient in the flank position, the needle can be inserted in the iliac fossa or upper quadrant [2]. The insertion site should always be away from previous surgical scars to reduce the risk of visceral injury.

3.3. Optical port access

Optical ports have a conical nonbladed trocar tip and allow visualisation of tissue layers as they are encountered via a 0° telescope. A firm, constant, alternating clockwise–anticlockwise motion is used perpendicular to the skin while CO2 is insufflated. The angle is reduced on entering peritoneum.

Despite visualisation of tissue layers, these ports cannot prevent serious injuries as outlined by the review of the Food and Drug Administration's database by Sharp et al. [6]. A single large review of their use in urological surgery, however, showed their relative safety with only a 0.31% risk of injury [7]. An example of an optical port is shown in Fig. 3.

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Fig. 3

Ethicon Hasson blunt port (left) and optical 12-mm port (right).

4. Aetiology of port-site complications

Factors involved in the causation of port site related complications are multifactorial and relate to patient and surgeon factors as well as port design (Fig. 4).

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Fig. 4

Aetiology of port site complications.

4.1. Patient factors

4.1.1. Obesity

Obesity is an ever-increasing problem. Reports in the United States describe a 10% increase in prevalence each decade [8]. Obesity has been shown to increase the incidence of both renal and prostate cancer; therefore, on extrapolation it is likely that the proportion of obese patients undergoing laparoscopic surgery may increase [9].

A thick layer of adipose subcutaneous tissue limits access, especially to the insertion of the initial camera port. The angle of insertion is more critical as this adipose layer limits free rotational movement of working ports. Ports need to be placed closer to the operation site, or longer ports and instruments must be used. The potential risk of misplacement of ports with associated injury is also higher for those choosing initial Verres needle insufflation [9]. Open Hasson access requires a larger skin incision to see in the obese patient, and overall operation time is generally prolonged.

Very thin patients are also potentially at risk of trocar-related injury, mainly with the primary port, as adjacent organs and major vessels are much closer to the abdominal wall [10].

4.1.2. Previous surgery in the area of interest

This can influence laparoscopy in many ways. It may cause difficulty in placing a Verres needle because of abdominal wall adhesions and limitations in proper insufflation. To avoid potential injury, trocar sites should be placed away from previous scars, which may result in a suboptimal location, increasing the potential for vascular/visceral injury. Subsequent lysis of adhesions may also increase the risk of injury to adjacent structures [11].

In retroperitoneal laparoscopy, a previous significant breach of the retroperitoneum increases the potential for significant adhesions and limitations in creating sufficient working space.

4.1.3. Medical comorbidity

The risk of wound infection is increased with significant medical comorbidity or immunosuppression.

Variation in the course and size of parietal vessels attributable to inferior vena caval obstruction or portal hypertension are also susceptible to provoking unexpected injuries to parietal vessels [12].

4.2. Surgeon factors

Surgeon experience is paramount in reducing the rate of port-site and other complications. The large multicentre German study [13] of 2407 laparoscopic urological procedures clearly showed an increased overall complication rate during the first 100 compared with subsequent cases (13.3% vs 3.6%). The incidence of trocar-related complications was 0.2%, but we are unaware if proportionately more occurred in their earlier cases.

With experience comes skill at accurate port placement, preventing inadvertent injury as well as maximising surgical ergonomics, and, therefore, reducing fatigue.

This fact again raises the importance of adequate training for urologists interested in laparoscopic surgery. Training should begin with structured didactic and laboratory training courses during residency and should finish with laparoscopic fellowships or mentoring during the surgeon's learning curve. There are two well-recognised programs requiring structured credentialing for certification; they are coordinated by the Endourologic Society and the European Society of Uro-Technology. In the United Kingdom, a nine-phase fellowship program, proposed under the guidance of the British Association of Urological Surgeons and other urological governing bodies, requires a certain number of supervised cases for competency [14] and [15].

4.3. Port design

Improvement in telescope and camera design has allowed for smaller diameter ports to be used, potentially reducing wound-related complications. Port design has also improved significantly since the beginning of urological laparoscopy. Initially pyramidal cutting trocars were the mainstay. Trocars with shielded blades were then developed and are still the preferred port type in many centres. More recently nonbladed trocars are increasingly being used as a growing number of studies suggest reduced complication rates [16]. These ports spread muscle and fascia rather than incise it and theoretically allow spontaneous reapproximation after trocar removal. A randomized prospective multicentre trial [17] comparing radially expanding trocars to standard cutting trocars, in gastrointestinal surgery, has shown significantly reduced wound complications in the radial expansion group.

An unpublished comparison of five different abdominal access trocar systems revealed significantly reduced fascial defect size for radially expanding and conical tip separating ports when compared with shielded cutting ports [18].

4.3.1. Hand ports

Hand assistance for nephrectomy was first reported by Tierney et al. in 1994 [19]. In 1996 the first hand laparoscopic port was approved by the Food and Drug Administration in the United States, and many centres are using hand-assisted laparoscopy when removing large specimens. It gives surgeons added confidence while they master advanced laparoscopic procedures by allowing the advantages of tactile feedback, ability to palpate, blunt dissection, and easier control of bleeding and specimen removal [20]. This approach helps bridge the gap between open and laparoscopic surgery; however, it is associated with higher complication rates in some series. Okeke et al. [21] reported their early results using the hand-assisted approach with 5 of 13 patients experiencing a major complication or needing conversion. With larger wounds come the potential for higher rates of wound infection and incisional herniae (1.9% each [22]).

Port design and the ergonomy of port placement should also take into account the possibility of diathermy injuries to the muscles or to the skin attributable to inadvertent use of energy in contact with metallic shafts in nondisposable ports.

5. Port-site complications and their prevention

5.1. Vascular injuries

Vascular injuries are the most commonly encountered injuries, ranging from an insignificant skin edge ooze to a catastrophic major vessel laceration requiring rapid open conversion [23] (Table 1). The incidence in Fahlenkamp's large urological multicentre series of trocar insertion complications was 0.2%, although it is unclear what proportion was solely vascular. Interestingly this group favours the blind Verres needle insufflation technique over the Hasson open technique and justify this preference with the very low complication rate [13]. A large review of mainly gynaecological laparoscopies in Germany between 1978 and 1982 totalling almost 300,000 reported a major vascular injury rate of 0.07% [24]. This rate is similar to a French report of ∼100 000 laparoscopic operations, which found an incidence of 0.045%. Local haemorrhage from the trocar site was the most frequent complication with an incidence of 0.21%, with 11.3% of these cases requiring conversion most likely related to epigastric vessel injury. The sites of injury from most to least common were iliac vein, greater omental vessels, inferior vena cava (IVC), aorta, pelvic and superior mesenteric veins, and lastly lumbar veins [25].

Table 1

Prevention and management of port-site complications

ComplicationPreventionManagement
Vascular
Abdominal wallTransilluminate to visualise superficial veinsBipolar diathermy
 Use hand-held Doppler to detect epigastricsSuture ligation preferable (closure device)
 Use conical/radially dilating ports 
Major vesselMinimise port insertion forceVenous:
 Insert ports under visionApply pressure (gauze, surgical) ±3rd assistant via extra port
  Increase insufflation pressure
  Clip/suture closure
  Arterial
  Apply pressure
  Attempt suture if small; often requires rapid conversion to open
VisceralUse open insertion of primary port and visual insertion of secondary portsLiver/spleen:
 Use access away from area of previous surgery if possibleApply pressure (gauze, surgical)
  Increase insufflation pressure
  Cautiously consider suture if bleeding is ongoing
  Consider thrombin sealants
  Bowel:
  Small bowel:
  - Laparoscopic suture repair/staple
  Colonic (low risk):
  - Suture repair
  - IV antibiotics and drainage
  Colonic (high risk):
  - Open repair, washout, and proximal diversion
Port-site herniaFormally close ≥10-mm cutting tip portsMaintain high index of suspicion
 Include peritoneum in musculofascial closure if possible (port closure device)Early: Laparoscopic reduction and repair possible
 Consider radially expanding or conical tip portsLate: Standard open Mayo/mesh repair
Wound infectionProphylactic IV antibiotic at inductionIV antibiotic±drainage guided by culture and sensitivity results
Surgical emphysemaKeep insufflation pressure ∼12mm HgIf severe, mechanical hyperventilation±cardiovascular support
 Accurate port placement under vision 
Port-site metastasesOptimise patient's fitness for surgery preoperativelyConsider:
 Adequately secure trocars to avoid inadvertent removal or use self-retaining trocarsExcision
 Minimise skin/fascial defect size to avoid periport leakage of gasChemoradiation if tumour sensitive
 Avoid direct tumour handling and breaching of tumour boundaries 
 Always use a bag for intact removal of specimen 
 Morcellate only within specific impermeable bags after consideration of seeding risk and review of literature 
 Drain surgical bed fluid and deflate pneumoperitoneum with ports in situ before removal 
 Consider povidine-iodine irrigation of port-site wounds 
 Consider closure of port sites ≥10mm to reduce exposure of raw wound surfaces [28] 

The German review [25] and a large Dutch review [26] found a higher rate in the closed technique compared with open port insertion.

Optical ports were initially touted as being safer than blind insertion; however, a review [6] of FDA reports outlined 37 major vascular injuries of aorta, IVC, and iliac vessels, and four deaths attributable to vascular injury.

5.2. Prevention

The decision to use the Verres needle or perform open Hasson cannulation to establish access is based on the surgeon's preference and individual experience. Open insertion is favourable, however, in the presence intra-abdominal adhesions, or alternatively a 2-mm needle scope may be used [13]. The results of a recent meta-analysis [27] of all open and closed laparoscopy conclude that open laparoscopy eliminates the risk of major vascular injury and reduces the rate of major visceral injuries. The authors conclude that open laparoscopy using the Hasson cannula should be the preferred method of peritoneal access.

Prior to insertion of the secondary ports, the abdomen should be transilluminated in dim theatre lighting to avoid visible superficial veins, and the operator must use surface anatomic landmarks to avoid major vessels. This approach however is a poor substitute for laparoscopic visualisation of inferior epigastric vessels, which run between the internal oblique and transversus abdominis [28]. On-table, duplex ultrasound preinsertion could also be used [29].

The use of radially expanding ports has been shown in a prospective randomized trial to cause significantly less abdominal wall bleeding (0% vs 10.57%; p=0.001). These ports utilise an initial Verres needle with a surrounding expandable sheath that is dilated after needle removal to the size required with a blunt plastic trocar [17]. These ports are reported to push vessels aside and create smaller abdominal wall defects as for all conical blunt/bladeless ports [30]. Examples of such ports are shown in Fig. 2.

At the end of the procedure, ports should be removed and sites inspected under direct laparoscopic vision with minimal insufflation pressure. Any bleeding should be directly controlled under vision. Suture ligation is preferable over extensive diathermy if bleeding is significant and can be accomplished intracorporally via a figure eight stitch or via the use of a port closure device [31].

If significant repair is needed, great vessel injury, or aortic or iliac artery injuries generally need conversion to an open approach. Major venous injuries however have a greater potential for laparoscopic repair. Insufflation pressure is increased to 15mm Hg; atraumatic graspers can hold edges together while closure takes place with a running suture requiring skilled assistance [Gill, personal communication, 2005].

Port-site incisions, which are extended to allow intact removal of specimens, are potentially more prone to vascular injury and require meticulous haemostasis.

5.3. Visceral injuries

The true incidence of visceral injuries in urological laparoscopy related purely to port placement is not reported. Analysis of gynaecologic and general surgical literature reveals an incidence between 0.06% and 0.08%. A large retrospective study [26] from the Netherlands compared open versus closed laparoscopy. There was a significantly reduced rate of visceral and vascular injury in the open Hasson technique (0.048% and 0% vs 0.083% and 0.075%, respectively; p=0.002). Open placement is not without risk however: Brill et al. [32] reported two cases of visceral injury with primary open access and 14 of 22 trocar injuries in a large Swiss retrospective review. It does however allow for earlier recognition and repair [33].

It is apparent that most significant injuries are created by the insertion of the primary port and are more common in the presence of adhesions from previous surgery. Previous transperitoneal surgery in the quadrant of interest is certainly a relative argument for subsequent retroperitoneal access to avoid this risk in renal surgery. It is associated with longer operative time and increased hospital stay; however, in a retrospective review of urological laparoscopies at Johns Hopkins, the operative blood loss and complication and conversion rate were not significantly increased [11]. A literature review of bowel injury in laparoscopy by Bishoff et al. [34] revealed that, of all injuries, 58% occurred in the small bowel, 32% in the colon, and 7% in the stomach.

5.3.1. Management of a visceral injury

Management of visceral injury depends on the structure involved and the likelihood of subsequent complication. Shekarriz et al. [35] in their study using radially expanding ports for renal/adrenal surgery used a closed technique for primary access. They reported a 9% rate of liver puncture with the initial Verres needle insertion; none however required intervention. Laparoscopic repair of liver or splenic injuries using thrombin sealants is technically feasible and has been reported in blunt trauma [36].

Obvious bowel injury requires meticulous repair. Several reports demonstrate the safety of laparoscopic repair if it recognised early and repaired at the same time. If there is a delayed diagnosis then almost all require laparotomy [34].

5.4. Port-site hernia

The incidence of port-site herniation is proportional to the size of the fascial defect remaining postprocedure. It is likely that this complication is under-reported for a number of reasons such as failure or delay to diagnose, patient tolerance of asymptomatic hernia, and reporting bias [37].

A survey [38] of the American Association of Gynaecologic Laparoscopists reported an incidence of 0.02%. In a study [39] using sharp pyramidal trocars, the rate was much higher at 1.8%. The multicentre review [13] of German urological laparoscopic procedures reported a rate of 0.2%. A retrospective review [22] of hand port-site complications in renal surgery, as expected, reported a higher rate of 1.9%. Evisceration and superficial wound dehiscence also occurred at the same rate. Laparoscopy with intact removal of the specimen is associated with higher postoperative incisional hernia rates attributable to the larger wound required. A review [40] of 29 cases with specifically large kidneys or malignancy revealed a 17% hernia rate with a 10.4-cm average incision length.

Trocar site hernias have been classified into early and late onset. The early hernias are associated with small-bowel obstruction. The attending surgeon must be aware that a classic bulge will not be present if associated with a Richter's hernia in which only a portion of the intestinal wall lies within the peritoneal defect. Late-onset hernias occur several months later and present with an obvious bulge [41].

The following key points may help to prevent port-site herniation:

  • Formally close ≥10-mm port sites created by cutting trocars [41].
  • Include peritoneum in musculofascial closure if possible [42].
  • Consider using radially expanding ports or other blunt ports, which produce smaller fascial defects [17].

There is evidence on short-term follow-up (6–18 mo) from Bhoyrul et al. [17] that radially expanding port sites ≥10mm do not require closure. Unpublished results from a prospective multicentre trial [43] of gynaecologic laparoscopy using blunt, nonradially expanding ports concluded that routine closure of up to 12-mm port sites was not required. This observation has to be balanced against case reports of herniation occurring in 5-mm ports [44]. Sound clinical judgement must prevail.

Studies [45] comparing extraperitoneal and retroperitoneal approaches rarely comment on port-site hernia rates. In a comparison of laparoscopic prostatectomy, 1% of transperitoneal versus 0% of extraperitoneal approaches were complicated by a hernia at the port site.

5.5. Wound infection

Wound infection postlaparoscopy is uncommon with a rate of 0.2% in one large series of urological cases [13]. This rate is higher in hand port sites and varies from 1.9% to 15.4% depending on the series [21] and [22].

Most laparoscopic cases in urology can be classified as clean/clean contaminated. A meta-analysis [46] of antibiotic prophylaxis in elective surgery presented the following recommendations for clean-contaminated and clean operations in presence of prostheses:

  • First/second-generation cephalosporin or amino penicillin/β lactamase inhibitors are optimal choices.
  • The highest licensed dosage should be given at induction.
  • Redosing should be considered when surgery lasts >2 half- lives.

No specific studies look specifically at urological laparoscopy and prophylaxis. Each unit should develop their own prescribing policy in consultation with their local microbiologic department.

For established port-site infection, initial intravenous antibiotic and drainage as required is usually all that is needed.

5.6. Preperitoneal gas

Preperitoneal gas is usually mild and limited to the abdominal wall and is due to malposition of the insufflation port allowing CO2 gas to track in the preperitoneal, retroperitoneal, or subcutaneous spaces. This allows a greater surface area for CO2 absorption, producing hypercapnia and respiratory acidosis, which rarely can track extensively to involve the neck, mediastinum, and pericardium (pneumothorax and/or pneumomediastinum) with reports of cardiovascular collapse [47].

Treatment is only required in severe cases and requires prolonged mechanical hyperventilation to correct the hypercapnia together with cardiovascular support if required.

5.7. Port-site metastases

Port-site metastases are a well-described but rare complication. In the urological literature, Micali et al. [48] describes 13 of the 10,912 (0.1%) laparoscopic cases sampled in an international retrospective audit. This finding compares favourably with the reported incidence of scar metastases in open radical nephrectomy of 0.4% [49].

The relative incidence parallels the biologic aggressiveness of the individual tumour subtype. The incidence after laparoscopic pelvic L/N dissection for prostate cancer is 0.1% compared with 4% for transitional cell carcinoma [50].

The pathophysiology of port-site metastases is not completely understood, although many clinical and experimental studies highlight four major factors.

5.7.1. Natural tumour biology

The tumour stage and grade have a direct impact on recurrence. The violation of tumour boundaries may promote dissemination of malignant cells with subsequent implantation of port sites [51]. Port-site metastases may also represent purely disseminated disease and act as a marker for biologic aggressiveness. Rassweiler et al. [52] concluded that tumour biology and immunosuppression status were the main factors in both local recurrence and port-site metastases rather than the technical aspects of laparoscopy.

5.7.2. Local wound factors

Murphy et al. [53] reported that tumour cells implant more effectively in the early stages of wound healing, by adhering to wound margins and connecting to fibrin. Aoki et al. [54] also showed peritoneal implantation was enhanced by trocar site trauma to the peritoneum. On the basis of this evidence, Tsivian [51] hypothesised that closure of the peritoneum at the trocar site may reduce the incidence of port-site metastases.

5.7.3. Patient's immune status

Surgical trauma depresses the body's immune system contributing, in theory, to local recurrence and metastases [55]. Studies [56] highlight the benefits of the laparoscopic approach in preserving opsonization and cell-mediated immunity. Surrogate markers of the immune response (interleukin 6, C-reactive protein) have been studied and, when the laparoscopic approach is used, reveal a weaker systemic response in major urological cases with less theoretical immune system depression [57].

  • Pneumoperitoneum. There is conflicting evidence in the ability of pneumoperitoneum to promote port-site metastases. These studies [51], [58], and [59] are a collection of animal and nonurological cases that make it difficult to assess their relevance. Further investigation is needed to make a recommendation.
  • Tumour cell aerosolization and periport gas leakage. This phenomenon has also been extensively investigated in general surgical literature. Many groups agree that shedding of aerosolised tumour cells occurs during pneumoperitoneum [60]. However others conclude that this event is not relevant and that sudden desufflation of the abdomen with transport of tumour cell–laden haemoserous fluid to the port site is a more likely mechanism [61] and [62]. The role of this “chimney effect” with leakage of gas around the port remains unclear.
  • Surgical manipulation and specimen retrieval. A lack of tactile feedback in laparoscopic surgery together with excess tumour handling, more commonly by an inexperienced surgeon, increases the potential for port-site metastases [63] and [64]. If ports are not adequately anchored to prevent inadvertent removal, the process of reinsertion may allow contamination of the port site by tumour-laden instruments. The method of specimen removal is also potentially important. Although the use of an entrapment sac is standard practice, many centres choose to morcellate their tumour-laden specimens rather than remove them intact to minimise wound size. This procedure must be performed only in purpose-built morcellation sacs to avoid perforation. Surgeons performing laparoscopic oncology procedures need to make an informed decision on whether intact removal or morcellation is preferable. Although morcellation maximises the minimally invasive nature of laparoscopy, it limits interpretation of histologic grade and stage of the tumour cells, and provides no information on margin and presence of lymphovascular invasion, thus impacting prognosis prediction [65].
5.7.5. Prevention of port-site metastases

Various cytotoxic agents have been studied in an effort to find a clinically useful and simple way to prevent port-site metastases. Animal studies have shown a reduced incidence by the use of 5-fluorouracil, cyclophosphamide, or methotrexate irrigation. A simpler method is the use of 5% povidine-iodine solution to irrigate the port site [66].

Review of the proposed aetiologic factors above highlights many potential preventive steps that the laparoscopic urologist should take [51]:

  • Optimise patient's fitness for surgery preoperatively.
  • Adequately secure trocars to avoid inadvertent removal, or use self-retaining trocars.
  • Minimise skin/fascial defect size to avoid periport leakage of gas.
  • Avoid direct tumour handling and breaching of tumour boundaries.
  • Always use a bag for intact removal of specimen.
  • Only morcellate within specific impermeable bags after consideration of the seeding risk and review of the literature.
  • Drain surgical bed fluid and deflate pneumoperitoneum with ports in situ before their removal.
  • Consider povidine-iodine irrigation of port-site wounds.
  • Consider closure of port sites ≥10mm to reduce exposure of raw wound surfaces.

6. Conclusions

Although uncommon, a wide range of potential complications associated with urological port-site placement exists with significant impact on perioperative morbidity and convalescence. To maintain minimal invasiveness in the face of ever-changing technology and robotic-assisted surgery, the operator needs to be adequately trained not only in the procedure but also in the recognition, treatment, and prevention of such complications.

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Footnotes

a Sir Charles Gairdner Hospital, Perth, Australia

b Scottish Lithotriptor Centre, Edinburgh, United Kingdom

c Department of Urology, Institut Jules Bordet, Brussels, Belgium

lowast Corresponding author. Tel. +44 131 537 1602; Fax: +44 131 537 1020.