RCTs have not been performed, nor will be performed , in order to document the incidence and the prevention of small bowel herniation in trocar sites. Indeed it is a rare complication and for obvious ethical reasons trials will not be performed. The evidence therefore can only be circumstantial.   We would try to summarise as follows our attitude.

1. The risk of small bowel herniation is believed to depend  on trocar diameter and on the surgical lesion caused by trocar insertion.

2. Unfortunately I am not aware of evidence that the risk of small bowel herniation is decreased by the use of conical trocars instead  of sharp triangular trocars or by the use of  the Termanian trocar. This could be expected given a smaller trauma as demonstrated years ago by Malcom Munro.

3. For the first intra publical trocar the risk seems so low that most of us will not suture the fascia. A plausible explanation could be that the insertion  is generally slightly oblique and that hte insertion thus closes by a flap valve mechanism.  For this reasons,  we only close the fascia of the first trocar insertion when either the patient is extremely thin or afther the incision has been enlarged for specimen retrieval.

4. For the secondary trocars which are inserted perpendicularly (in order to permit eventual backloading of sutures)  we do not close the fascia for 5 mm ports but always close them when 10mm or larger ports were used.

5. The biggest clinical challenge, however, is the diagnosis of a small bowel herniation since symptomatology is insidious.  For this reason, we advocate an early repeat laparoscopy whenever a patient does not improve progressively after laparoscopic surgery. This will permit the eventual diagnosis and treatment of most postoperative complications such as  small bowel herniation or perforation, late perforation of the colon or ureter, bleeding or infection. We feel so stronly about the liberal use of early repeat laparoscopy that we accept 25% or more negative (and thus unnecessary ) repeat laparoscopies.

*Dpt obstetrics and gynaecology KULeuven, Belgium  and ** gruppo Italo Belga , Rome Italy.