Laparoscopic cholecystectomy and the umbilicus

Pre-existing umbilical defects may present technical problems in patients having laparoscopic surgery. Fascial defects may also occur after operation. Understanding the causes and mechanisms of herniation at laparoscopic port sites may help avoid potentially serious postoperative complications.

The incidence, management and potential complications of pre-existing and postoperative umbilical defects were studied in 870 patients undergoing laparoscopic cholecystectomy.

The incidence of umbilical or paraumbilical defects was 12 per cent. The hernias were symptomatic in only 16.3 per cent; the majority of patients were unaware of the defect. The umbilical port was established through, or directly adjacent to, the defect, allowing simple anatomical repair in 90 per cent, using absorbable sutures. The recurrence rate was 3.8 per cent; recurrence was usually caused by wound extension or infection. Incisional hernia occurred in 16 patients after cholecystectomy (1.8 per cent). Only one hernia developed at a port site other than the umbilicus. Risk factors associated with incisional hernia were wound extension in 12 patients, male sex in six, wound infection in five, diabetes in four, pre-existing umbilical hernia in four and acute cholecystitis in three.

The significant incidence of umbilical defects in patients undergoing laparoscopic surgery calls for accurate diagnosis and good technique. The incidence of incisional hernia might be reduced by avoiding unnecessary wound extension and the use of non-absorbable sutures for defects larger than 2 cm and in men with umbilical hernia.