8-mm Port Site Hernia After Robotic Right Hemicolectomy in a Dialysis Patient: Is 8-mm Closure Necessary? A Case Report

8-mm Port Site Hernia After Robotic Right Hemicolectomy in a Dialysis Patient: Is 8-mm Closure Necessary? 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A Case Report Fumi Hasegawa, Miyako Tazawa, Naruhiko Tokuhashi, Mika Nakata, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8143333/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Port site hernia (PSH) is a rare but important complication of minimally invasive surgery. While fascial closure is generally recommended for ports 10 mm or larger, the necessity of closing 8mm robotic ports remains controversial. We report a case of PSH at an 8 mm port site following robot-assisted right hemicolectomy in a dialysis patient. An 83-year-old man with ascending colon cancer and a history of chronic hemodialysis underwent robotic right hemicolectomy, with an operative time of 353 minutes. The initial postoperative course was uneventful, but on postoperative day 21 he developed abdominal pain. Computed tomography (CT) imaging revealed small bowel herniation through the 8-mm port site in the right lower abdomen, with signs of incarceration and obstruction. Laparoscopic exploration showed a 10- mm fascial defect, which was closed with 0-Vicryl sutures using an Endo Close™ (Medtronic, Minneapolis, MN, USA). The patient recovered without recurrence. The PSH in this case was likely caused by multiple factors, including prolonged operative time, tissue fragility associated with advanced age and long-term dialysis, and increased intra-abdominal pressure. Dialysis-related loss of collagen and elastic fibers may have further reduced tissue elasticity. A review of 21 reported PSH cases at 8-mm robotic ports showed that most occurred in the lower abdomen and frequently required bowel resection. Although PSH at 8-mm ports is rare, its potential for incarceration and emergency surgery underscores laparoscopic inspection of port sites before completing the procedure. Fascial closure should be considered for high-risk patients, particularly those with tissue fragility, such as individuals on chronic dialysis. 8 mm port hemodialysis port site hernia right hemicolectomy robotic surgery Figures Figure 1 Figure 2 Figure 3 Background Port site hernia (PSH) is a known complication of laparoscopic surgery. It has been suggested that fascial closure is required for port sites 10 mm or larger, whereas 5-mm ports may not require closure 1) . As the number of robot-assisted surgeries continues to increase worldwide, establishing clear criteria for fascial closure at 8-mm port sites is becoming increasingly important. With the increasing prevalence of robot-assisted surgeries worldwide, a consensus on whether to close 8 mm port sites may be established in the future. We experienced a case of PSH at an 8 mm port site following robot-assisted right hemicolectomy in a patient with multiple risk factors, including advanced age and chronic dialysis. Based on this experience, we highlight the need to consider fascial closure in high-risk patients undergoing robotic surgery. Case presentation An 83-year-old male was diagnosed with ascending colon cancer. His Body mass index(BMI) was 23.1 kg/m². He has a medical history of hypertension, stroke, and chronic kidney failure due to IgA nephropathy, for which he had been undergoing hemodialysis for the past four and a half years. He had no history of steroid use. He underwent robotic-assisted right hemicolectomy with D3 lymph node dissection for a diagnosis of ascending colon cancer T4aN0M0 cStageIIB. The port placement is shown in Fig. 1 . The total operation time was 353 minutes (console time: 216 minutes), with a blood loss of 42 ml. The postoperative course was uneventful, and he was discharged on the fifth postoperative day. On postoperative day 21, he experienced abdominal pain while returning home from shopping and was readmitted the following day. A contrast-enhanced CT scan revealed small bowel herniation through the 8mm port site in the right lower quadrant. There was proximal dilatation of the small bowels indicating the presence of incarceration and obstruction (Fig. 2 ). Manual reduction was possible; however, the hernia orifice measured approximately 10 mm, indicating a potential risk of recurrent incarceration. Therefore, we decided to perform surgical intervention. Surgical findings: The surgery was performed laparoscopically. A camera port was placed at the same site during the previous right hemicolectomy. The 8mm port site in the lower right abdomen had a hernia orifice of approximately 10mm, while the other port sites showed scarring of the abdominal wall (Fig. 3 a, b, c). The hernia orifice was closed with 0-Vicryl sutures using the Endo Close™ device (Fig. 3 d). The operation time was 23 minutes. Postoperatively, there have been no recurrences of the hernia. Discussion and Conclusions The reported frequency of PSH following laparoscopic surgery ranges from 0.01% to 4.0%. Stabilini et al. conducted a meta-analysis and reported a 0.02% incidence of PSH after colorectal resection 2) . Damani et al. state that the incidence of PSH in robot-assisted surgery is 0.13%, and considering asymptomatic cases, the actual incidence may be underreported. 3) . Another study found that 6.7% of patients who underwent robot-assisted urologic surgery had PSH detected by CT scan, suggesting that PSH may occur more frequently in robot-assisted surgeries compared to conventional laparoscopic procedures 4) . Several mechanisms have been proposed to explain the potentially higher incidence of PSH in robotic surgeries: ①misalignment of the remote center causing fascial injury at the port site 5) . ②longer operative times and greater torque applied by robotic arms compared with human operators, resulting in increased strain on the fascia and progressive enlargement of the port holes 6) . ③lateral positioning of ports to maintain adequate spacing, which places them near the iliac crest where closure is technically difficult due to reduced tissue elasticity and sliding 7) . In this case, PSH occurred at the site of fenestrated bipolar forceps, which are frequently employed for grasping and traction. Continuous pressure exerted by robotic instruments at a fixed fulcrum point may stretch the parietal peritoneum and fascia more than manual manipulation in laparoscopic surgery. This sustained force, compounded by a prolonged operative time, could have contributed to enlargement of the fascial defect. Patients on long-term dialysis often exhibit reduced skin and connective tissue integrity, which may have contributed to PSH in this patient. Chronic ischemia-reperfusion injury caused by repeated blood flow changes during dialysis, along with factors such as dry weight management, dehydration due to fluid restriction, and vascular calcification from phosphorus–calcium deposition, can lead to the loss of collagen and elastic fibers, thereby reducing tissue elasticity 8) . These pathological changes are accompanied by oxidative stress and the generation of reactive oxygen species, further promoting the degradation of collagen and elastic fibers and ultimately diminishing tissue viscoelasticity. Additionally, epidermal thickness in dialysis patients is significantly reduced compared with healthy individuals 9) , further suggesting an increased risk of hernia development due to weakened skin integrity. In healthy individuals, intra-abdominal pressure (IAP) averages 1.8 mmHg in the supine position, 16.7 mmHg when sitting, and 20.0 mmHg when standing, increasing to 81.4 mmHg during coughing and up to 171 mmHg during jumping 10) . Peritoneal dialysis further elevates IAP, especially in the inguinal region, and is a known risk factor for inguinal hernia development 11) . Therefore, increased physical activity after discharge may elevate IAP, particularly in the lower abdomen, contributing to the risk of hernia at lower abdominal port sites. A PubMed search using the keywords “port site hernia” and “robot” identified 21 detailed cases of PSH occurring at 8-mm port sites (Table 1). Only two cases involved upper abdominal ports, while the remainder occurred in the lateral or lower abdomen, consistent with the higher IAP in these regions. Although most cases presented early after surgery (2–13 days), several reports described delayed onset, as in the present case (beyond 20 days and up to 6 months), highlighting the need for extended postoperative vigilance. All reported cases were identified because of bowel obstruction due to incarceration, often requiring surgical intervention, with seven cases required small bowel resection. The median BMI of 24.2 (range: 19.7–43) indicates that obesity is not a major risk factor for PSH at 8-mm port sites. Possible contributing factors to PSH at the 8-mm port in this case include: (1) enlargement of the fascial defect due to prolonged operative time. (2) reduced tissue elasticity and epidermal thinning related to advanced age and long-term dialysis; and (3) increased IAP from postoperative activities exerting stress on the lower abdominal port site. Although PSH at 8-mm ports is rare, it may result in incarceration requiring emergency surgery or bowel resection. Therefore, in patients with risk factors such as prolonged operative time, tissue fragility, or increased intra-abdominal pressure -particularly in individuals with reduced tissue integrity such as those undergoing long-term dialysis- laparoscopic inspection of port sites before completing the procedure is recommended, and fascial closure should be considered when any enlargement or weakness of the abdominal wall is observed. Abbreviations PSH: Port-site hernia, IAP: Intra-abdominal pressure, CT: Computed tomography, BMI: Body mass index Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent for publication of this case report and accompanying images were obtained from the patient. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this study. Authors’ contributions FH collected clinical data, analyzed the literature, and drafted the manuscript. MT, NT and MN assisted the acquisition of the data. FH was a major contributor in writing the manuscript. AK and ME contributed to manuscript revision. All authors read and approved of the final manuscript. Acknowledgements We would like to thank the surgical staff and nursing team for their support in managing this patient. Authors’ information Not applicable. References Emilie L, Romain B, Valérie P, Frédéric R, Francesco V, Philippe M. 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A rare case of interparietal incisional hernia from 8 mm trocar site after robot-assisted laparoscopic prostatectomy. Hernia. 2014; 18: 911-3. Mariangela M, Marialaura R, Fabrizio M, Filiberto Z. Incidence and Treatment of Incarcerated Trocar-Site Hernias After Robotic Surgery: Presentation of Three Cases. J Endourol Case Rep. 2020; 6: 271-274. Leigh S, Floor B, Kimberly R, David C. Robotic trocar site small bowel evisceration after gynecologic cancer surgery. Obstet Gynecol. 2008; 112: 462-4. Massimiliano S, Shea S, Ikechukwu O, Jason V, Roxie A, Carson W. Trocar site spigelian-type hernia after robot-assisted laparoscopic prostatectomy. Urology. 2009; 73: 1423.e3-5. Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Apr, 2026 Reviews received at journal 12 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviews received at journal 07 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Editor invited by journal 29 Jan, 2026 Reviewers invited by journal 10 Jan, 2026 Editor assigned by journal 20 Nov, 2025 Submission checks completed at journal 20 Nov, 2025 First submitted to journal 18 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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15:03:29","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51260,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8143333/v1/cf2af03b2727596353c9db74.html"},{"id":97271652,"identity":"fa115286-4aa5-434a-a137-95b19dde5e46","added_by":"auto","created_at":"2025-12-02 15:03:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":124731,"visible":true,"origin":"","legend":"\u003cp\u003ePort placement for robotic-assisted right hemicolectomy\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8143333/v1/30f5cb68b9f307eeab12dffb.png"},{"id":97368626,"identity":"9e9951b6-6ffc-4975-93da-a55ba4576107","added_by":"auto","created_at":"2025-12-03 16:22:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":210161,"visible":true,"origin":"","legend":"\u003cp\u003eEnhanced CT scan.\u003cbr\u003e\nSmall bowel loops herniated through the 8-mm port site in the lower right quadrant, with proximal small bowel dilatation.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8143333/v1/8feecbc09562d473dbf304b1.png"},{"id":97271654,"identity":"875f21d1-6ec2-4152-84dd-96bc964bde0c","added_by":"auto","created_at":"2025-12-02 15:03:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":413833,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings.\u003cbr\u003e\n \u003cstrong\u003e(a)\u003c/strong\u003e The 8-mm port site in the lower right abdomen formed a hernia orifice approximately 10 mm in diameter.\u003cbr\u003e\n \u003cstrong\u003e(b, c)\u003c/strong\u003e The other port sites showed scarring of the abdominal wall.\u003cbr\u003e\n \u003cstrong\u003e(d)\u003c/strong\u003e The hernia orifice was closed with 0-Vicryl sutures using the Endo Close™ device.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8143333/v1/22168920ba47e57974dece8c.png"},{"id":97372892,"identity":"ddfd264c-eebf-40ba-9fa8-a743da4250ad","added_by":"auto","created_at":"2025-12-03 16:33:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1387874,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8143333/v1/7f60a4ce-54d6-4556-a20d-94dd63a685aa.pdf"},{"id":97368826,"identity":"d53b2aa9-810c-4abb-a517-8635006d71bb","added_by":"auto","created_at":"2025-12-03 16:23:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17147,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8143333/v1/37d4726eb57ef72af5249fa5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"8-mm Port Site Hernia After Robotic Right Hemicolectomy in a Dialysis Patient: Is 8-mm Closure Necessary? A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003ePort site hernia (PSH) is a known complication of laparoscopic surgery. It has been suggested that fascial closure is required for port sites 10 mm or larger, whereas 5-mm ports may not require closure\u003csup\u003e1)\u003c/sup\u003e. As the number of robot-assisted surgeries continues to increase worldwide, establishing clear criteria for fascial closure at 8-mm port sites is becoming increasingly important. With the increasing prevalence of robot-assisted surgeries worldwide, a consensus on whether to close 8 mm port sites may be established in the future. We experienced a case of PSH at an 8 mm port site following robot-assisted right hemicolectomy in a patient with multiple risk factors, including advanced age and chronic dialysis. Based on this experience, we highlight the need to consider fascial closure in high-risk patients undergoing robotic surgery.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eAn 83-year-old male was diagnosed with ascending colon cancer. His Body mass index(BMI) was 23.1 kg/m². He has a medical history of hypertension, stroke, and chronic kidney failure due to IgA nephropathy, for which he had been undergoing hemodialysis for the past four and a half years. He had no history of steroid use. He underwent robotic-assisted right hemicolectomy with D3 lymph node dissection for a diagnosis of ascending colon cancer T4aN0M0 cStageIIB. The port placement is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The total operation time was 353 minutes (console time: 216 minutes), with a blood loss of 42 ml. The postoperative course was uneventful, and he was discharged on the fifth postoperative day. On postoperative day 21, he experienced abdominal pain while returning home from shopping and was readmitted the following day. A contrast-enhanced CT scan revealed small bowel herniation through the 8mm port site in the right lower quadrant. There was proximal dilatation of the small bowels indicating the presence of incarceration and obstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Manual reduction was possible; however, the hernia orifice measured approximately 10 mm, indicating a potential risk of recurrent incarceration. Therefore, we decided to perform surgical intervention.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSurgical findings:\u003c/p\u003e\u003cp\u003eThe surgery was performed laparoscopically. A camera port was placed at the same site during the previous right hemicolectomy. The 8mm port site in the lower right abdomen had a hernia orifice of approximately 10mm, while the other port sites showed scarring of the abdominal wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea, b, c). The hernia orifice was closed with 0-Vicryl sutures using the Endo Close™ device (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). The operation time was 23 minutes. Postoperatively, there have been no recurrences of the hernia.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThe reported frequency of PSH following laparoscopic surgery ranges from 0.01% to 4.0%. Stabilini et al. conducted a meta-analysis and reported a 0.02% incidence of PSH after colorectal resection\u003csup\u003e2)\u003c/sup\u003e. Damani et al. state that the incidence of PSH in robot-assisted surgery is 0.13%, and considering asymptomatic cases, the actual incidence may be underreported. \u003csup\u003e3)\u003c/sup\u003e. Another study found that 6.7% of patients who underwent robot-assisted urologic surgery had PSH detected by CT scan, suggesting that PSH may occur more frequently in robot-assisted surgeries compared to conventional laparoscopic procedures \u003csup\u003e4)\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSeveral mechanisms have been proposed to explain the potentially higher incidence of PSH in robotic surgeries: ①misalignment of the remote center causing fascial injury at the port site \u003csup\u003e5)\u003c/sup\u003e. ②longer operative times and greater torque applied by robotic arms compared with human operators, resulting in increased strain on the fascia and progressive enlargement of the port holes \u003csup\u003e6)\u003c/sup\u003e. ③lateral positioning of ports to maintain adequate spacing, which places them near the iliac crest where closure is technically difficult due to reduced tissue elasticity and sliding\u003csup\u003e7)\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this case, PSH occurred at the site of fenestrated bipolar forceps, which are frequently employed for grasping and traction. Continuous pressure exerted by robotic instruments at a fixed fulcrum point may stretch the parietal peritoneum and fascia more than manual manipulation in laparoscopic surgery. This sustained force, compounded by a prolonged operative time, could have contributed to enlargement of the fascial defect.\u003c/p\u003e\u003cp\u003ePatients on long-term dialysis often exhibit reduced skin and connective tissue integrity, which may have contributed to PSH in this patient. Chronic ischemia-reperfusion injury caused by repeated blood flow changes during dialysis, along with factors such as dry weight management, dehydration due to fluid restriction, and vascular calcification from phosphorus–calcium deposition, can lead to the loss of collagen and elastic fibers, thereby reducing tissue elasticity\u003csup\u003e8)\u003c/sup\u003e. These pathological changes are accompanied by oxidative stress and the generation of reactive oxygen species, further promoting the degradation of collagen and elastic fibers and ultimately diminishing tissue viscoelasticity. Additionally, epidermal thickness in dialysis patients is significantly reduced compared with healthy individuals\u003csup\u003e9)\u003c/sup\u003e, further suggesting an increased risk of hernia development due to weakened skin integrity.\u003c/p\u003e\u003cp\u003eIn healthy individuals, intra-abdominal pressure (IAP) averages 1.8 mmHg in the supine position, 16.7 mmHg when sitting, and 20.0 mmHg when standing, increasing to 81.4 mmHg during coughing and up to 171 mmHg during jumping\u003csup\u003e10)\u003c/sup\u003e. Peritoneal dialysis further elevates IAP, especially in the inguinal region, and is a known risk factor for inguinal hernia development\u003csup\u003e11)\u003c/sup\u003e. Therefore, increased physical activity after discharge may elevate IAP, particularly in the lower abdomen, contributing to the risk of hernia at lower abdominal port sites.\u003c/p\u003e\u003cp\u003eA PubMed search using the keywords “port site hernia” and “robot” identified 21 detailed cases of PSH occurring at 8-mm port sites (Table\u0026nbsp;1). Only two cases involved upper abdominal ports, while the remainder occurred in the lateral or lower abdomen, consistent with the higher IAP in these regions. Although most cases presented early after surgery (2–13 days), several reports described delayed onset, as in the present case (beyond 20 days and up to 6 months), highlighting the need for extended postoperative vigilance. All reported cases were identified because of bowel obstruction due to incarceration, often requiring surgical intervention, with seven cases required small bowel resection. The median BMI of 24.2 (range: 19.7–43) indicates that obesity is not a major risk factor for PSH at 8-mm port sites.\u003c/p\u003e\u003cp\u003ePossible contributing factors to PSH at the 8-mm port in this case include: (1) enlargement of the fascial defect due to prolonged operative time. (2) reduced tissue elasticity and epidermal thinning related to advanced age and long-term dialysis; and (3) increased IAP from postoperative activities exerting stress on the lower abdominal port site.\u003c/p\u003e\u003cp\u003eAlthough PSH at 8-mm ports is rare, it may result in incarceration requiring emergency surgery or bowel resection. Therefore, in patients with risk factors such as prolonged operative time, tissue fragility, or increased intra-abdominal pressure -particularly in individuals with reduced tissue integrity such as those undergoing long-term dialysis- laparoscopic inspection of port sites before completing the procedure is recommended, and fascial closure should be considered when any enlargement or weakness of the abdominal wall is observed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePSH: Port-site hernia, IAP: Intra-abdominal pressure, CT: Computed tomography, BMI: Body mass index\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of this case report and accompanying images were obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFH collected clinical data, analyzed the literature, and drafted the manuscript. MT, NT and MN assisted the acquisition of the data. FH was a major contributor in writing the manuscript. AK and ME contributed to manuscript revision. All authors read and approved of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the surgical staff and nursing team for their support in managing\u003c/p\u003e\n\u003cp\u003ethis patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEmilie L, Romain B, Val\u0026eacute;rie P, Fr\u0026eacute;d\u0026eacute;ric R, Francesco V, Philippe M. Evaluation of port site hernias, chronic pain and recurrence rates after laparoscopic ventral hernia repair: a monocentric long-term study. Hernia. 2017; 21:917-923.\u003c/li\u003e\n\u003cli\u003eStabilini C, Garcia-Urena MA, Berrevoet F, et al. An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure. Hernia. 2022; 26:411-436.\u003c/li\u003e\n\u003cli\u003eTanuja D, Les J, Jason F, Paresh S. Incidence of acute postoperative robotic port-site hernias: results from a high-volume multispecialty center. J Robot Surg. 2021; 15: 457-463.\u003c/li\u003e\n\u003cli\u003eMatthew C, Jules M, Abdulaziz K, Afshan O, Karen W, Noah S. Occult Radiographically Evident Port-Site Hernia After Robot-Assisted Urologic Surgery: Incidence and Risk Factors. J Endourol. 2016; 30: 92-6.\u003c/li\u003e\n\u003cli\u003eTaiki O, Masayoshi N, Hiroki K. Port site hernia at the robotic arm port after robotic-assisted laparoscopic radical prostatectomy. IJU Case Reports. 2020; 3: 153-156.\u003c/li\u003e\n\u003cli\u003eTong Q, Ruojia L, Anai K, Michael A. Acute appendicitis within a robotic port-site hernia: a case report. J Surg Case Rep. 2020; 2: 1-2.\u003c/li\u003e\n\u003cli\u003eRamon D, Carlos P, Julian M, et al. Robotic port-site hernias after general surgical procedures. J Surg Res. 2018; 230: 7-12.\u003c/li\u003e\n\u003cli\u003eNagisa F, Sigeki S. Visual verification in skin-tear risk screening of dialysis patients. J. Jpn. WOCM. 2020; 24: 310-319. [In Japanese, English abstract]\u003c/li\u003e\n\u003cli\u003eLina K, Neira P, Dragan L, et al. Differences in epidermal thickness and expression of apoptosis regulatory proteins in the skin of patients with chronic renal failure and pruritus. Acta Histochem. 2013; 115: 144-50.\u003c/li\u003e\n\u003cli\u003eWilliam C, Justin B, Kent K, Brent M, James N, Todd H, Normal intraabdominal pressure in healthy adults. J Surg Res. 2005;129:231-5.\u003c/li\u003e\n\u003cli\u003eTwardowski, Prowant B, Nolph K, Martinez A, Lampton L. High volume, low frequency continuous ambulatory peritoneal dialysis. Kidney Int. 1983; 23: 64\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eHirotaka S, Keiji N, Ippei Y, Takehisa F. Preventing an 8-mm Port Site Hernia in Robot-Assisted Laparoscopic Surgery: Insights From Two Rare Cases and Future Preventive Measures. Cureus. 2024; 16: e56609. doi: 10.7759/cureus.56609.\u003c/li\u003e\n\u003cli\u003eChanggi Ahn, Masatsune Shibutani, Kishu Kitayama, et al. An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report. Surg Case Rep. 2024 ;10:75.doi: 10.1186/s40792-024-01878-x.\u003c/li\u003e\n\u003cli\u003eYeon H, Haerin P, Seul K, Jung L, Chang S. An 8-mm trocar-site hernia at a drainage insertion site after a three-port robotic myomectomy: case report and review of literature. J Surg Case Rep. 2024; 3: 189. doi: 10.1093/jscr/rjae189\u003c/li\u003e\n\u003cli\u003eAkinobu F, Eiji F, Koichi M et al. Eight mm Port-Site Hernia Following Robot-Assisted Abdominoperineal Resection for Rectal Cancer-A Case Report. Gan To Kagaku Ryoho. 2023; 50: 221-223. [In Japanese, English abstract]\u003c/li\u003e\n\u003cli\u003eAtsushi O, Kentaro H, Toru A et al. A Case of Port-Site Herniation from an Eight mm Port after Robot-Assisted Distal Gastrectomy. Gan To Kagaku Ryoho. 2020; 47: 2367-2369. [In Japanese, English abstract]\u003c/li\u003e\n\u003cli\u003eShoko U, Yousuke S, Kosuke O, Noriaki U, Sojun K. Port-site incisional hernia from an 8-mm robotic trocar following robot-assisted radical cystectomy: Report of a rare case. IJU Case Rep. 2020; 3: 97-99.\u003c/li\u003e\n\u003cli\u003eJames T, Ada N, Jason W, Edmond W, Kwan H, Ming Y. Trocar-site hernia at the 8-mm robotic port after robot-assisted laparoscopic prostatectomy: a case report and review of the literature. J Robot Surg. 2014; 8: 89-91.\u003c/li\u003e\n\u003cli\u003eTaiki O, Masayoshi N, Hiroki K et al. Port site hernia at the robotic arm port after robotic-assisted laparoscopic radical prostatectomy. IJU Case Rep. 2020; 3: 153-156.\u003c/li\u003e\n\u003cli\u003eRooma S, Rupa B, Girija. Acute Presentation of Port Site Hernia Following Robot-Assisted Hysterectomy: A Case Report and Review of the Literature. J Midlife Health. 2021; 12: 244-246.\u003c/li\u003e\n\u003cli\u003eGokhan K, Tevfik B, Omeri T, Ibrahim A, Teresa W, Olga S. Trocar site hernia on an 8-mm port following robotic-assisted hysterectomy. J Chin Med Assoc. 2014; 77: 112-4.\u003c/li\u003e\n\u003cli\u003eTong Q, Ruojia L, Ana K, Michael A, Michael A. Acute appendicitis within a robotic port-site hernia: a case report. J Surg Case Rep. 2020; 2: 399. doi: 10.1093/jscr/rjz399.\u003c/li\u003e\n\u003cli\u003eWon C, Tae Y, Sung K. Is the 8-mm robotic port safe? A case of trocar site hernia after robotic cholecystectomy using the da Vinci Xi system. Wideochir Inne Tech Maloinwazyjne. 2019; 14: 137-140.\u003c/li\u003e\n\u003cli\u003eMatthew C, Nicholas M, Shinban L, Josef S.\u003csup\u003e \u003c/sup\u003ePort site hernias following robotic colorectal surgery in people with obesity. BMJ Case Rep. 2018: bcr2018226155. doi: 10.1136/bcr-2018-226155.\u003c/li\u003e\n\u003cli\u003eElisabetta M, Eleonora R, Paolo M, et al. Severe bowel incarceration in an eight-millimeter left-lateral trocar site after robot-assisted laparoscopic colposacropexy: A case report. Case Rep Womens Health. 2019: 24: e00151. doi: 10.1016/j.crwh.2019.e00151.\u003c/li\u003e\n\u003cli\u003eLim S, Kim K, Shin T, Hong S, Choi Y, Rha K. A rare case of interparietal incisional hernia from 8 mm trocar site after robot-assisted laparoscopic prostatectomy. Hernia. 2014; 18: 911-3.\u003c/li\u003e\n\u003cli\u003eMariangela M, Marialaura R, Fabrizio M, Filiberto Z. Incidence and Treatment of Incarcerated Trocar-Site Hernias After Robotic Surgery: Presentation of Three Cases. J Endourol Case Rep. 2020; 6: 271-274.\u003c/li\u003e\n\u003cli\u003eLeigh S, Floor B, Kimberly R, David C. Robotic trocar site small bowel evisceration after gynecologic cancer surgery. Obstet Gynecol. 2008; 112: 462-4.\u003c/li\u003e\n\u003cli\u003eMassimiliano S, Shea S, Ikechukwu O, Jason V, Roxie A, Carson W. Trocar site spigelian-type hernia after robot-assisted laparoscopic prostatectomy. Urology. 2009; 73: 1423.e3-5.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"8 mm port, hemodialysis, port site hernia, right hemicolectomy, robotic surgery","lastPublishedDoi":"10.21203/rs.3.rs-8143333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8143333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePort site hernia (PSH) is a rare but important complication of minimally invasive surgery. While fascial closure is generally recommended for ports 10 mm or larger, the necessity of closing 8mm robotic ports remains controversial. We report a case of PSH at an 8 mm port site following robot-assisted right hemicolectomy in a dialysis patient. An 83-year-old man with ascending colon cancer and a history of chronic hemodialysis underwent robotic right hemicolectomy, with an operative time of 353 minutes. The initial postoperative course was uneventful, but on postoperative day 21 he developed abdominal pain. Computed tomography (CT) imaging revealed small bowel herniation through the 8-mm port site in the right lower abdomen, with signs of incarceration and obstruction. Laparoscopic exploration showed a 10- mm fascial defect, which was closed with 0-Vicryl sutures using an Endo Close\u0026trade; (Medtronic, Minneapolis, MN, USA). The patient recovered without recurrence.\u003c/p\u003e\u003cp\u003eThe PSH in this case was likely caused by multiple factors, including prolonged operative time, tissue fragility associated with advanced age and long-term dialysis, and increased intra-abdominal pressure. Dialysis-related loss of collagen and elastic fibers may have further reduced tissue elasticity. A review of 21 reported PSH cases at 8-mm robotic ports showed that most occurred in the lower abdomen and frequently required bowel resection. Although PSH at 8-mm ports is rare, its potential for incarceration and emergency surgery underscores laparoscopic inspection of port sites before completing the procedure. Fascial closure should be considered for high-risk patients, particularly those with tissue fragility, such as individuals on chronic dialysis.\u003c/p\u003e","manuscriptTitle":"8-mm Port Site Hernia After Robotic Right Hemicolectomy in a Dialysis Patient: Is 8-mm Closure Necessary? 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