Is fascial closure required for a 12-mm trocar?A comparative study on trocar site hernia with long-term follow up

BACKGROUND Despite the infrequency of trocar site hernias(TSHs),fascial closure continues to be recommended for their prevention when using a≥10-mm trocar.AIM To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries.METHODS Between July 2010 and December 2018,all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed.All patients underwent cross-sectional imaging for TSH assessment.Clinicopathological characteristics were recorded.Incidence rates of TSH and postoperative results were analyzed.RESULTS Of the 254 patients included,70(111 ports)were in the fascial closure(closed)group and 184(279 ports)were in the nonfascial closure(open)group.The median follow up duration was 43 mo.During follow up,three patients in the open group developed TSHs,whereas none in the closed group developed the condition(1.1%vs 0%,P=0.561).All TSHs occurred in the right lower abdomen.Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain.The open group had a significantly shorter operative time and lower blood loss than the closed group.CONCLUSION Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed.However,further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen:a randomized controlled trial

Background:Fluid overload(FO)after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen(OA)patients.Bioelectrical impedance analysis(BIA)is a promising tool for monitoring fluid status and FO.Therefore,we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.Methods:A pragmatic,prospective,randomized,observer-blind,single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center.A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation(defined as BIA)protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level(HL)measured by BIA or a traditional fluid resuscitation(TRD)in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 d of intensive care unit(ICU)management.The primary outcome was the 30-day primary fascial closure(PFC)rate.The secondary outcomes included the time to PFC,postoperative 7-day cumulative fluid balance(CFB)and adverse events within 30 d after OA.The Kaplan–Meier method and the log-rank test were utilized for PFC after OA.A generalized linear regression model for the time to PFC and CFB was built.Results:A total of 134 patients completed the trial(BIA,n=66;TRD,n=68).The BIA patients were significantly more likely to achieve PFC than the TRD patients(83.33%vs.55.88%,P<0.001).In the BIA group,the time to PFC occurred earlier than that of the TRD group by an average of 3.66 d(P<0.001).Additionally,the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml(P<0.001)and fewer complications.Conclusions:Among postinjury OA patients in the ICU,the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.