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Page 8 of 13 Koc et al. Mini-invasive Surg 2018;2:7 I http://dx.doi.org/10.20517/2574-1225.2017.33

S. aureus were isolated and empiric antibiotic treatment was replaced by cefazolin 4 g/day. At the 7th day,
the drainage tube was removed due to reduction in lymphocele size. Two months after, CT showed no
[59]
recurrence .
Thromboembolism
Thromboembolism includes deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE). It
[60]
is a serious complication with a low incidence as < 1% . Generally, redisposing factors are venous stasis,
vascular damage and hypercoagulability. Intermittent compressive devices (ICDs) or low-molecular-weight
heparin (LMWH) should be used in prophylaxis. ICDs reduce only the DVT rate, however LMWH reduces
[61]
both the DVT and PTE rates significantly .

Trochar site hernia
Trocar site hernia (TSH) is a serious uncommon complication and mostly requires surgical intervention.
[62]
[63]
The overall incidence ranges from 0% to 5.2% . TSH was reported at 5 mm or even smaller port sites .
[64]
TSH may also develop at the complete fascial closure sites, even though fascial closure prevents TSH .
TSH may also develop despite the use of bladeless and radially dilating trocars that are designed specially
[65]
to decrease the fascial and muscular defect size . In facts, nearly 4 of the reported cases were shown as
related with the high prevalence of the procedure RARP [66-68] .
Predisposing situations for post-operative TSH development should be evaluated according to underlying
mechanisms. Technical and surgical factors include the size of the trocar site fascial defect, use of the
cutting or non-bladed trocars, time period of the surgery, port locations (midline or paramedian),
excessive manipulation at the port site leading to stretching of the fascia layers, specimen retrieval, angle
of the trocar insertion and fascial closure at the end of the procedure. Patient factors include obesity, some
postoperative factors such as cough or chronic constipation resulting in increased intraabdominal pressure,
and factors affecting wound healing such as chemotherapy, diabetes mellitus, infection, malnutrition or
[69]
smoking .
[70]
Tsu et al. published a TSH case report in 2013. Patient has the bilateral open inguinal herniography
history with recurrence at the left side requiring subsequent laparoscopic hernioplasty. RARP with bilateral
[71]
pelvic lymphadenectomy was performed by the 6-port trans-peritoneal approach described by Pick et al. .
The 12-mm periumbilical port site used for the camera was enlarged at the level of specimen retrieval.
This enlarged port site and the 12-mm assistant port site were closed with polydiaxanone at the fascial
level. A 5-mm assistant port and three 8-mm robotic arm ports were closed at the skin level only. On the
postoperative 4th day, patient had abdominal pain, distension and notable tender bulge near the 8-mm
robotic arm port scar. Abdominal radiographs revealed ileus and CT showed that the bowel herniated
through a fascial defect at the left 8-mm port site. Mini laparotomy was performed over the defect. In
exploration, a loop of small bowel was found as trapped between the external and internal oblique muscles.
The bowel loops were returned to the peritoneal cavity. Fascial layers of the laparotomy were closed
[70]
separately with polydiaxanone. The patient represented an uneventful recovery .
In classical laparoscopy, the fascial port sites smaller than 10 mm may not be closed since the technical
[66]
difficulties. However, the robotic arms generate a larger torque in the abdominal wall . This information
[66]
explains why TSH occurs after RARP. Seamon et al. advised inserting surgical plugs into the 8 mm
port site fascial defects when fascia is not closed. To avoid an excessively large fascial defect and enlarged
[67]
preperitoneal space, Spaliviero et al. recommended inserting the 8 mm port at a 60 -90 angle and
o
o
closing the fascial layers in patients with risk factors for hernia development.
[69]
Lim et al. reported a small bowel obstruction case due to an interparietal trocar site hernia after RARP.
They recommended that 8 mm robotic trocar sites, associated with a large peritoneal defect, should be
carefully closed at the end of surgery.