2024 Military Poster Presentations

James Fraley, MD; Navtej S Grewal, MD; Kelly Tang, DO; Samuel L Grasso, DO; William Beaumont Army Medical Center

Introduction: Laparoscopic cholecystectomy is classically performed with three or four abdominal port sites. It is one of the most common surgeries performed in the United States, as well as our military academic hospital. Among the port sites, one is typically larger (10-12mm) than the rest of the 5mm port sites to facilitate removal of the gallbladder and to utilize larger instruments. Placement of this incision at the epigastric or umbilical region is debated by surgeons today, in addition to whether to close this incision with fascial sutures to reduce the risk of postoperative incisional hernia. We hypothesize that the epigastric placement of the larger incision decreases risk of incisional hernia, even without the addition of fascial sutures.

Methods: This is a retrospective study of cholecystectomies performed at WBAMC from January 2015 to August 2021. Data was sourced from the electronic medical record to examine operative technique and if the patients developed an incisional hernia in the first 18 months postoperatively.

The inclusion criteria are all patients who had a laparoscopic cholecystectomy performed at WBAMC over the above timeframe. The exclusion criteria are known hernias at time of surgery, connective tissue disorders, conversion to open procedure, and previous ventral or umbilical hernia repair.

Results: The data collection from this series demonstrated a total of 1,133 cholecystectomies being performed during the timeframe of interest. Of these, 1,062 satisfied inclusion criteria, with 397 (37.4%) utilizing a larger umbilical incision and 665 (62.6%) utilizing a larger epigastric incision. Among the larger umbilical incision group, 392 patients (98.7%) received fascial closure compared to 527 patients (79.2%) in the larger epigastric incision group. Upon chart review, there were no identified instances of incisional hernia at 18 months among all patients.

Discussion: This review demonstrates that there is non-inferiority of foregoing fascial closure of the larger laparoscopic port site with respect to incisional hernia at 18 months. Of note, there was a higher rate of closure of the umbilical port site compared to the epigastric port site, likely due to the use of Hasson technique, limiting the ability to see if location of the larger incision affected risk of port site hernia in settings where fascial closure was not performed. Additionally, data was limited by no means of active surveillance during the 18-month postop period, as such patients could have developed asymptomatic hernias for which evaluation, diagnosis, or repair was never performed.