828 A rare situation: herniation of bowel through 5 mm trocar site in a patient wıth endometrial carcinoma

Introduction/Background* Hernia formation through 5mm-trocar-site has incidence between 1-6% in the literature. Practically fascial defect at the 10-mm-trocar site is closed, while suturing at the 5-mm-trocar site is not preferred. Because of its rarity, a possible hernia can be underestimated by the clinician and severe intestinal damage may occure as complication of minimally invasive surgery. Here we present a case -who had been operated via laparoscopy due to endometrial carcinoma-with bowel strangulation at 5mm-trocar site in the 4thpostoperative day. Methodology CASE PRESENTATION A 69-years old patient had referred to our hospital with the diagnosis of endometrial carcinoma. Minimal invasive staging approach with laparoscopic hysterectomy, bilateral salpingooferectomy and pelvic¶-aortic-lymph-node-dissection was performed. A 10-mm-trocar at the umblical site was inserted with direct technique, and bilateral accessory trocars of 5-mm (two left, one right) were placed under direct visualization. Second 10-mm-trocar positioned as suprapubically was also entered to abdomen for performing para-aortic lymph node dissection. After the operation abdominal drain was introduced from left inferior 5mm trocar site. Fascial defect in umblical and suprapubic trocar sites were sutured via vicryl suturing and skin insicions were closed. Patient had no abnormal symptoms throughout early postoperative period. Spontaneous flatus passage was occured in the 2ndpostoperative day. On the 4thpostoperative day she had non-severe discomforting symptoms as a subtle abdominal pain and nausea. A palpable, 8 cm, subdermal mass was diagnosed on abdominal examination and abdominal computerized-tomography was performed for a suspected early postoperative incisional hematoma or hernia. Bowel-herniation was diagnosed on CT-imaging (figure 1) and exploratory laparotomy was performed for GIS pathology. During operation midline abdominal incision was made and 30 cm herniated small bowel herniation without strangulation was diagnosed at the left superior 5mm-trocar-site. No segmental-bowel-resection was performed upon surgery because bowel-segment vascularity and peristaltism were evaluated as well preserved during exploration. Result(s)* Patient was followed up clinically by physical examination, abdominal drainage and leucocyte and C-reactive-protein levels. On the 7thday after secondary surgery patient was discharge without any further complication. Conclusion* Early detection of trochar-site-hernia is important because of leading severe morbidity, such as intestinal strangulation and necrosis. After laparoscopic surgery, in the case of unexplained intestinal obstuction and abdominal pain, abdominal-CT imaging is very helpful in diagnosis.