To review complications associated with urological laparoscopic port-site placement and outline techniques for their prevention and management.
Review of the literature using Medline.
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.
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.
Keywords: Laparoscopy, Port site, Complications, Access.
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)
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.
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
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
3.1. Open access using the Hasson technique
Many centres including the authors favour the Hasson technique
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 800
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 (1
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
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.
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 (
4.1. Patient factors
Obesity is an ever-increasing problem. Reports in the United States describe a 10% increase in prevalence each decade
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
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
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
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
4.2. Surgeon factors
Surgeon experience is paramount in reducing the rate of port-site and other complications. The large multicentre German study
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  and .
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
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
4.3.1. Hand ports
Hand assistance for nephrectomy was first reported by Tierney et al. in 1994
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
Optical ports were initially touted as being safer than blind insertion; however, a review
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
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
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
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
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 15
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
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
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.
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
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
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
The following key points may help to prevent port-site herniation:
- • Formally close ≥10-mm port sites created by cutting trocars .
- • Include peritoneum in musculofascial closure if possible .
- • Consider using radially expanding ports or other blunt ports, which produce smaller fascial defects .
There is evidence on short-term follow-up (6–18 mo) from Bhoyrul et al.
5.5. Wound infection
Wound infection postlaparoscopy is uncommon with a rate of 0.2% in one large series of urological cases
Most laparoscopic cases in urology can be classified as clean/clean contaminated. A meta-analysis
- • 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
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.
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
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
5.7.2. Local wound factors
Murphy et al.
5.7.3. Patient's immune status
Surgical trauma depresses the body's immune system contributing, in theory, to local recurrence and metastases
5.7.4. Factors related to laparoscopy
- • Pneumoperitoneum. There is conflicting evidence in the ability of pneumoperitoneum to promote port-site metastases. These studies , , and  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 . 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  and . 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  and . 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 .
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
Review of the proposed aetiologic factors above highlights many potential preventive steps that the laparoscopic urologist should take
- • 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.
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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