Obesity Surgery, 12, 121-123 © FD-Communications Inc. Obesity Surgery, 12, 2002 121 Background: Port site herniation is an uncommon event that usually occurs as a result of incomplete fascial closure. This allows the omentum or viscera to herniate through the incompletely closed defect. However, in laparoscopic surgery for morbid obesity, the omentum and viscera can herniate through the thick preperitoneal space even with a complete clo- sure of the fascia. Case Report: A 19-year-old female with BMI 55 underwent uneventful long limb laparoscopic Roux- en-Y gastric bypass. On postoperative day 1 the patient had limited pain, was ambulating well, and was tolerating sips of liquids. A limited upper GI series performed on postoperative day 2 revealed no leak or obstruction. Several hours later the patient developed abdominal pain associated with nausea, which progressed to vomiting. CT of the abdomen suggested a port site herniation into the left sub- costal port. The cause of the obstruction appeared to be herniation through the left subcostal port site. At laparotomy, a segment of bowel just distal to the anastomosis was found herniated through the port site. The Richter’s hernia was reduced. Careful inspection of the fascia revealed a complete fascial closure, with the strangulated portion of the bowel incarcerated in the preperitoneal space. Following repair of the preperitoneal defect, her subsequent recovery was unremarkable. Conclusion: Laparoscopic surgery for morbid obe- sity presents the possibility for preperitoneal hernia- tion. Closure, using a fascial closure device, under laparoscopic control, may offer a solution by closing both the fascia and peritoneum all at once. Key words: Morbid obesity, bariatric surgery, laparoscopy, bowel obstruction, hernia, Richter’s Introduction Port site herniation is an uncommon but well described complication of laparoscopic surgery. 1 It usually results from a lack of or an incomplete clo- sure of the fascia. 2-4 This allows the omentum or viscera to herniate through the fascial defect. However, in laparoscopic surgery for morbid obe- sity, the omentum and viscera can herniate through the thick preperitoneal space, even with a complete closure of the fascia. 5 Case Report A 19-year-old female with a BMI of 55 underwent an uneventful long limb laparoscopic Roux-en-Y gastric bypass. A 3-cm left subcostal incision, through which the head of a 25-mm circular stapler (US Surgical, Norwalk, CT, USA) was inserted, was closed extracorporeally with two figure-of- eight sutures. On the first postoperative day, the patient was ambulating well and tolerating sips of liquids. A limited upper GI series performed on the second postoperative day revealed no anastomotic leak. Twelve hours later, she developed nausea, which progressed to vomiting. A repeat contrast study was performed, which again revealed no proximal or distal anastomotic defects and no bowel obstruc- tion. Physical examination did not reveal any evi- dence of an acute incisional hernia. Because of Reprint requests to: Daniel R. Cottam, 31 Woodpecker Lane, Levittown, NY 11756, USA. E-mail: danamycottam@yahoo.com Case Report Preperitoneal Herniation Into a Laparoscopic Port Site Without a Fascial Defect Daniel R. Cottam, MD; Piotr J. Gorecki, MD; Marcio Curvelo, MD; David Weltman, MD; L. D. George Angus, MD; Gerald Shaftan, MD Nassau University Medical Center, Department of Surgery, East Meadow, NY, USA