Incisional hernia after laparoscopy was reported in more than 900 cases (98,99). The most common defect is dehiscence that develops in the immediate postoperative period. Hernias may be asymptomatic or may cause pain, fever, periumbilical mass, obvious evisceration, and the symptoms and signs of mechanical bowel obstruction. Although no incision is immune to the risk, defects that are larger than 10 mm in diameter are particularly vulnerable (99,142,143).
Richter’s hernias contain only a portion of the intestine in the defect, and the diagnosis is often delayed because the typical symptoms and findings of mechanical bowel obstruction may be absent. The initial symptom is usually pain. These hernias most often occur in incisions that are lateral to the midline where there is a greater amount of preperitoneal fat creating a potential space for incarceration. Fever can be present if incarceration occurs, and peritonitis may result from subsequent perforation. The condition is difficult to diagnose, requires a high index of suspicion, and may be confirmed with ultrasonography or CT (144).
In most cases, these occurrences can be prevented by using small-caliber cannulas, when possible, and with routine fascial and peritoneal closure of defects made by peritoneal access. The risk of inadvertent incorporation of the intestine into the wound can be reduced by viewing the closure with a smaller-caliber laparoscope passed through a narrow caliber ancillary port. All ancillary cannulas should be removed under direct vision to ensure that bowel is not drawn into the incision and that there is an absence of active incisional bleeding.
The management of laparoscopic incisional defects depends on the time of presentation and the presence and condition of entrapped bowel. Evisceration always requires surgical intervention. If the condition is diagnosed immediately, the intestine is replaced in the peritoneal cavity (if there is no evidence of necrosis or intestinal defect), and the incision is repaired, usually with laparoscopic guidance. If the diagnosis is delayed or the bowel is incarcerated or at risk of perforation, laparotomy is necessary to repair or resect the intestine.
Wound infections after laparoscopy are uncommon; most are minor skin infections that can be treated successfully with expectant management, drainage, or antibiotics (145). Severe necrotizing fasciitis rarely occurs. Bladder infection, pelvic cellulitis, and pelvic abscess were reported (146).
Laparoscopy is associated with a much lower risk of infection than open abdominal or vaginal surgery. Prophylactic antibiotics should be offered to selected patients (e.g., those with enhanced risk for bacterial endocarditis and those for whom total hysterectomy is planned). Patients should be instructed to monitor their body temperature after discharge and to report immediately a temperature higher than 38◦C.