Multiple Trocar-Site Hernias Following Robot-Assisted Incisional Hernia Repair: A Case Report

Trocar-site hernia (TSH) is a recognized complication of minimally invasive surgery. Current guidelines suggest fascial closure for trocar sites of 10 mm or larger. However, there is limited evidence regarding the necessity of fascial closure for 8-mm trocar sites. The occurrence of multiple TSHs in a single patient following robot-assisted surgery has not been well documented. We present a rare case of three simultaneous TSHs at 8-mm robotic port sites following a robot-assisted incisional hernia repair.  A 69-year-old male with a BMI of 28.8 kg/m² presented with a symptomatic umbilical trocar-site incisional hernia following prior laparoscopic inguinal hernia repair, with an associated 3-4 cm diastasis recti. He underwent a robot-assisted incisional hernia repair using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) via a ventral transabdominal preperitoneal approach with mesh reinforcement. Three 8-mm robotic trocars were used in the left lateral position, and fascial closure of these trocar sites was not performed. At two-week follow-up, the patient reported a new lump at the left inferior trocar site. Computed tomography confirmed a TSH containing fat in this location, which was subsequently confirmed intraoperatively to be omentum. Thirty-two days after the index operation, the patient underwent robot-assisted incisional hernia repair of this new hernia. At the time of the operation, three separate TSHs were identified at all three prior 8-mm port sites, measuring 5 mm at the left superior defect, 5 mm at the left middle defect, and 2 cm at the left inferior defect. The omentum was noted to be contained in all three sites but was incarcerated at the inferior hernia. After reduction of the omentum, the hernias were repaired with musculofascial closure and mesh reinforcement with significant overlap of more than 2 cm. The new trocar sites were closed prior to completion of the case. The patient's subsequent recovery was uncomplicated with no evidence of recurrence.  This case demonstrates that multiple TSHs may develop at all 8-mm robotic trocar sites in a single patient, with early symptom onset and rapid progression to incarceration. A history of multiple or recurrent hernias should prompt consideration of prophylactic fascial closure of all trocar sites, regardless of trocar size. Further research is needed to establish evidence-based guidelines for fascial closure of 8-mm robotic ports and to identify patients who may benefit from prophylactic closure.