A multidisciplinary analysis of 8-mm port-site hernias in 2,337 robotic ports and the realities of its risk factors.

Abstract

Background: Port-site hernia (PSH) at 8-mm robotic trocar sites is considered uncommon, and routine fascial closure is generally not recommended. However, clinically significant PSH continues to occur, and its underlying mechanisms remain incompletely understood. This study aimed to evaluate the incidence and risk factors of 8-mm PSH after robotic-assisted surgery and to explore practical preventive strategies.

Methods: We retrospectively analyzed 816 patients who underwent robotic-assisted surgery across the gastrointestinal, hepatobiliary-pancreatic, urological, and gynecological specialties between January 2020 and December 2024. A total of 2337 8-mm ports were included, all of which were left without fascial closure. Patient characteristics, port locations, drain placement and size, operative times, and perioperative factors were evaluated in patients who developed PSH.

Results: The median BMI of the overall cohort was 22.9 kg/m² (range 11.0-48.9 kg/m²). The incidence of 8-mm PSH was 0.49% per patient (4/816) and 0.17% per port (4/2337). All PSH cases occurred at lateral abdominal wall port sites in non-obese patients (body mass index <25 kg/m²). Three of the four cases (75%) developed at drain insertion sites, and symptoms appeared shortly after drain removal. The median total operative time was 323.5 min in the PSH group versus 317 min in the non-PSH group. All hernias were Richter-type hernias. Clinical findings suggested a multifactorial mechanism involving mechanical enlargement of the fascial defect by robotic torque, impaired muscular shutter mechanisms at lateral abdominal sites, and drain-related factors that prevented spontaneous fascial closure.

Conclusions: Eight-millimeter PSH is a rare but potentially preventable complication of robotic-assisted surgery. The risk appears to be concentrated in non-obese patients with lateral abdominal wall ports, particularly when these sites are used for drain placement. Intraoperative digital assessment of the fascial defect using the "pinky test" may facilitate selective fascial closure of high-risk port sites and help reduce the occurrence of this complication.