Users Online : 5277 About us |  Subscribe |  e-Alerts  | Feedback | Login   |   
Journal of Minimal Access Surgery Current Issue | Archives | Ahead Of Print Journal of Minimal Access Surgery
           Print this page Email this page   Small font sizeDefault font sizeIncrease font size 
 ¤   Similar in PUBMED
 ¤  Search Pubmed for
 ¤  Search in Google Scholar for
 ¤Related articles
 ¤   Article in PDF (1,228 KB)
 ¤   Citation Manager
 ¤   Access Statistics
 ¤   Reader Comments
 ¤   Email Alert *
 ¤   Add to My List *
* Registration required (free)  

 ¤  Abstract
 ¤ Introduction
 ¤  Materials and Me...
 ¤ Results
 ¤ Discussion
 ¤ Conclusion
 ¤ Acknowledgement
 ¤  References
 ¤  Article Figures
 ¤  Article Tables

 Article Access Statistics
    PDF Downloaded650    
    Comments [Add]    
    Cited by others 13    

Recommend this journal


 Table of Contents     
Year : 2013  |  Volume : 9  |  Issue : 2  |  Page : 59-64

Analysis of laparoscopic port site complications: A descriptive study

Department of General Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Date of Submission15-Nov-2011
Date of Acceptance02-Mar-2012
Date of Web Publication22-Apr-2013

Correspondence Address:
Alfred Joseph Augustine
Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka-575001
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9941.110964

Rights and Permissions

 ¤ Abstract 

Context: The rate of port site complications following conventional laparoscopic surgery is about 21 per 100,000 cases. It has shown a proportional rise with increase in the size of the port site incision and trocar. Although rare, complications that occur at the port site include infection, bleeding, and port site hernia. Aims: To determine the morbidity associated with ports at the site of their insertion in laparoscopic surgery and to identify risk factors for complications. Settings and Design: Prospective descriptive study. Materials and Methods: In the present descriptive study, a total of 570 patients who underwent laparoscopic surgeries for various ailments between August 2009 and July 2011 at our institute were observed for port site complications prospectively and the complications were reviewed. Statistical Analysis Used: Descriptive statistical analysis was carried out in the present study. The statistical software, namely, SPSS 15.0 was used for the analysis of the data. Results: Of the 570 patients undergoing laparoscopic surgery, 17 (3%) had developed complications specifically related to the port site during a minimum follow-up of three months; port site infection (PSI) was the most frequent (n = 10, 1.8%), followed by port site bleeding (n = 4, 0.7%), omentum-related complications (n = 2; 0.35%), and port site metastasis (n = 1, 0.175%). Conclusions: Laparoscopic surgeries are associated with minimal port site complications. Complications are related to the increased number of ports. Umbilical port involvement is the commonest. Most complications are manageable with minimal morbidity, and can be further minimized with meticulous surgical technique during entry and exit.

Keywords: Complication, laparoscopy, ports, port site bleed, port site hernia, port site infection

How to cite this article:
Karthik S, Augustine AJ, Shibumon MM, Pai MV. Analysis of laparoscopic port site complications: A descriptive study. J Min Access Surg 2013;9:59-64

How to cite this URL:
Karthik S, Augustine AJ, Shibumon MM, Pai MV. Analysis of laparoscopic port site complications: A descriptive study. J Min Access Surg [serial online] 2013 [cited 2022 Jul 3];9:59-64. Available from:

 ¤ Introduction Top

Laparoscopic techniques have revolutionized the field of surgery. Benefits include decreased postoperative pain, quicker return to normal activity, and less postoperative complications. However, unique complications are associated with gaining access to the abdomen for laparoscopic surgery. Inadvertent bowel injury or major vascular injury are uncommon but potentially life-threatening complications, usually occurring during initial access. [1],[2] The overall rate of major complications following a laparoscopic procedure is approximately 1.4 per 1,000 procedures. [3] However the incidence of port site complications following laparoscopic surgery is considered to be around 21 per 100,000 cases [4] and it has shown a proportional rise with the increase in size of the port site incision and trocar. [5],[6]

The overall complications/injuries that occur following laparoscopic surgeries involve, gastrointestinal (0.6 per 1,000), genitourinary (0.3 per 1000), vascular (0.1 per 1,000), and omentum (0.4 per 1,000). [7],[8] However, the rarer complications include pyoderma gangrenosum, [9] metastasis at the port site following laparoscopic oncosurgery, [10],[11] and port site infections (PSIs). [12] The aim of this study was to determine the morbidity associated with the port site in laparoscopic surgery and to identify risk factors for complications.

 ¤ Materials and Methods Top

All patients who underwent laparoscopic surgeries, between August 2009 and July 2011, at our institute in the Department of General Surgery were included and port sites were monitored for complications prospectively. A total of 570 cases were operated upon. Those with a past history of open abdominal surgery and who were converted to open procedures were excluded from the study.

All patients received antibiotics preoperatively. Reusable ports were used in 554 cases. In the remaining 14 cases, 12 mm disposable ports were used; they were reused in two cases after sterilization with ethylene oxide (ETO). Once the surgery was finished, all the instruments were removed carefully under vision. Fascia of ports ≥10 mm was closed. PSI was defined according to the National Nosocomial Infections Surveillance (NNIS) system. Centers for Disease Control and Prevention (CDC). [13] Wounds were assessed clinically after surgery and in case of infection, were treated with regular cleaning and dressing, with empirical oral antibiotics. PSI was studied in relation to frequency, type of surgery, and port position. Similarly, port site bleeding, was studied in relation to frequency, site, type of ports, and size of ports. Omentum-related complications were studied in relation to frequency, type of surgery, number of ports, and the port site involved. Further port site complications were studied in relation to age, sex, body mass index (BMI), total number of ports used, technique of port closure, and procedure performed.

 ¤ Results Top

In the current study, a series of 570 patients including 307 male and 263 female were operated. A total of 17 (3%) patients had port site complications [Table 1]. Complications were seen in 11 females and six males (p >0.05). Patients were in the age range of 13 to 80 years. Port site complications were common in the 20-40 age groups (p >0.05). Mean BMI was 23.2 (SD = 3.12) and had no significance in relation to the frequency of port site complications. Laparoscopic cholecystectomy was the most commonly performed procedure with highest port site complications (52.9%) in our study population.
Table 1: Procedure and port site complications (n = 17)

Click here to view

Most common ports involved were umbilical port sites (47%, n = 8) [Table 2]. Port site complications were significantly increased with increased number of ports (p = 0.23); however, a causal relationship could not be explained [Table 3]. Technique of port closure had no influence on incidence of complication; however, both the omentum-related complications were seen with conventional port closure.
Table 2: Site and type of complication

Click here to view
Table 3: Correlation of port size, number, and complications (n = 570)

Click here to view

Of 17 complications, 10 (58%) were due to PSI [Table 2]. All cases were superficial wound infections. Four (23.5%) patients developed port site bleeding; all were minor vessel injury during the placement of secondary trocars. The procedures involved were cholecystectomy (n = 2), total extraperitoneal repair TEP (n = 1), and appendectomy (n = 1). Bleeding was managed with electrocoagulation or lateral compression of ports. The ports involved were epigastric (n = 2), suprapubic port (n = 1), and left lateral lumbar port (n = 1).

Two patients had omentum-related complications at the port site (11.8%, n = 2). Those were immediate postoperative herniation/entrapment of the omentum from the site of umbilical (camera) port and late (3 months post surgery) herniation of the omentum from the umbilical port site scar (port site hernia). Both were associated with 10 mm ports and the fascia was closed by the conventional method. However, the present study did not show significant difference in the rate of complication between port closure needle and conventional suturing.

There was one case of port site metastasis (5.9%). The patient underwent laparoscopic-assisted hemicolectomy for adenocarcinoma of the ascending colon (pathological) stage 3. The specimen was removed with the midline incision extending through the umbilical port incision. Two months later, the patient developed recurrence from previous anastomotic site which was infiltrating to the anterior abdominal wall through the previous umbilical port site.

 ¤ Discussion Top

Port site complications can be grouped into access-related complications and postoperative complications, and have been reported in all age groups and in both genders. The literature shows that obesity is associated with increased morbidity related to port site due to various factors like the need for longer trocars, thick abdominal wall, need for larger skin incision to expose fascia adequately, and limitation in mobility of the instrument due to increased subcutaneous tissue. Care must be taken during placement of trocars to align their axes as needed for the procedure. In our study, there was no increase in the frequency of morbidity related to port site and obesity. The present study showed that cholecystectomy was the commonest procedure performed and more frequently associated with port site complications. This is comparable to observations made by Fuller et al. [14]

Neudecker et al. had shown that port site complications were increased with more number of ports. [15] Fascial closure is recommended for ports ≥10 mm; the fascia are closed with sutures to reduce the risk of developing a port site hernia. [16] Reapproximation of the fascia can be accomplished in a variety of ways. Ideally, the fascia is directly visualised with the aid of retractors. The fascial edges are grasped and the sutured closed with interrupted or continuous suture. A number of specialized instruments have been devised for fascial closure at the port site (e.g., Grice® suture needle, Carter-Thomson needle-point suture passer, Endo Close™ instrument, Reverdin suture needle). [17],[18] The benefit of these devices is yet to be proven. The technique of closure of the rectus sheath had no influence on our study.

Port site infection [Figure 1] (b-f)
Figure 1: (a): Port site hernia; (b-f): Port site infection; (g-i): Port site bleed; (j-l): Omental entrapment

Click here to view

Laparoscopic procedures have a reduced incidence of PSIs and other wound-related complications. [19] Nonetheless, they can produce significant morbidity. The presence of significant peri-incisional erythema, wound drainage, and fever may indicate the presence of a necrotizing fascial infection. [20] The incidence of PSI was 1.8%. Our results are comparable with many other studies. Den Hoed et al. found the incidence to be 5.3%, [21] Shindholimath et al. 6.3% [12] and Colizza et al. <2% [22] All PSIs were superficial, involving only the skin and subcutaneous tissue. Superficial skin infection is more common and has been reported by another study. [13] Umbilical port site was the most common site of PSI followed by epigastric port site. In the literature, there is great emphasis on the increased frequency of umbilical site PSIs and the role of umbilical flora in the development of PSIs. Emphasis is also there on the increased frequency of PSI and the trocar site of extraction. All gall bladder specimens in cholecystectomy were removed through the epigastric port. Wound infections are prevented by appropriate administration of antibiotic prophylaxis, sterile techniques, and the use of specimen bags during specimen extraction. Once present, infections are treated with drainage, packing, and antibiotics as appropriate.

Port site bleeding [Figure 1] (g-i)

Incidence of port site bleeding was found to be 0.7%. Our results are comparable with other studies. [23] All were associated with the placement of secondary trocars. There was no associated bleeding with port site dilatation for specimen removal. Injury to epigastric vessels can be related to carelessness during the operative procedure usually during the placement of secondary trocars which should be placed under direct vision and with prior illumination of the abdominal wall. Bleeding from the abdominal wall may not become apparent until after the port is removed because the port may tamponade muscular or subcutaneous bleeding. In addition to visually inspecting the access site upon its creation, the site should also be inspected during and following removal of the port. Bleeding points can usually be identified and managed with electrocautery. On occasion, the skin incision may need to be enlarged to control the bleeding. If persistent bleeding continues, a Foley catheter can also be inserted, inflated, and gentle traction applied to tamponade the site. Also, U-stitches can be placed into the abdominal wall under direct laparoscopic visualization using a suture passer with absorbable braided sutures. A number of specialized instruments have been devised for fascial closure at the port site and these may also be useful for managing abdominal wall bleeding.

Omentum-related complications [Figure 1] (a,j-l)

Two patients were found to have omentum-related complications at the port site. Incidence of omental complications was 0.4% and is comparable with other studies (0.02-1.6%). [24],[25],[26]

The risk of developing incisional hernia is low with the use of trocars ≤12 mm, radially dilating trocars, or bladeless trocars. [16] Most authors close fascial defects if a port >12 mm is used, regardless of site or type of trocar. Some advocate closure if >10 mm in size. [27] The fascia should be closed with suture to reduce the risk of developing a port-site hernia. [16] Although rare, hernia has been reported even for 5 mm trocar sites. When port site hernia is identified following laparoscopy, the site should be repaired to prevent the development of intestinal complications (i.e., obstruction, strangulation). [28] Various factors are attributed to the occurrence of these complications including a) removal of the ports prior to complete deflation of the peritoneal cavity, b) inadequate/faulty closure of the port site incisions, and c) large incision at the port site. [6] They can be avoided or managed as follows: a) After the procedure, all the ports should be removed under careful vision, b) all the accessory ports to be removed under vision followed by the releasing pneumoperitoneum by opening the valve of 10 mm cannulas, c) after release of gas is completed, the primary port and telescope are to be removed together, with a clear view at all times that the port is free of any entrapped bowel, d) to limit the size of the port incisions, and e) a secure and adequate closure of the port sites of size 10 mm and above should be ensured. Other documented omental complications include laceration and penetrating injuries of the omentum during insertion of the port, omental bleeding, [29] and granulomas of the omentum in the late postoperative period. [30]

Port site metastasis

In recent years, after laparoscopic oncological procedures, several reports of trocar site recurrence have been published. [10],[11] The exact mechanism of development of metastasis of the abdominal wall is unknown. However, various explanations are given in the literature. Studies show that recurrence of tumour at the port site probably can be avoided by the use of plastic bags or wound protectors to avoid direct contact between the tumour and the wound. It is also essential that extraction of the specimen is done through an abdominal incision wide enough to allow easy passage of the specimen.

Other complications associated with port sites are:

Failed entry: If bile, enteric contents, or blood returns at the placement of the Veress needle, the needle should be left in place and alternative access gained immediately.

Leaking port: If a port leaks during a procedure, it is usually due to the fascial defect being too large. This can be mitigated with additional sutures or the placement of a towel clamp to clinch the tissue closed around the trocar.

Loss of port position: If a port slides within the abdominal wall, the port may need to be repositioned and/or secured with additional sutures. The use of longer or larger diameter trocars may also be helpful.

Port site pain: Pain from placement of trocars is expected, but can be minimized by using the least number of ports required to perform the procedure safely,

Nerve injury: The location of port sites should be chosen to avoid abdominal wall nerves. Nerve injury is unlikely to be recognized intraoperatively, and usually results in persistent postoperative pain.

 ¤ Conclusion Top

Laparoscopic surgeries are associated with minimal port site complications. Complications at port site include wound infection, dehiscence, herniation of small bowel, entrapment of the omentum, bleeding, recurrence of tumour, and so on. Percentage wise, the incidence of these complications noted in the study is comparable with statistics worldwide (0.2 to 6). The commonest intraoperative complications were seen in secondary ports, though overall complications were more at the umbilical port. All complications were manageable with minimum morbidity. Consideration of meticulous surgical technique during entry and exit at all the port sites can minimize these complications further.

 ¤ Acknowledgement Top

The authors would like to thank Dr. Gopalakrishna Bhat, Associate Professor, Department of Microbiology, Kasturba Medical college, Mangalore, Manipal University for his guidance in preparing this manuscript.

 ¤ References Top

1.Ahmad G, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev 2008;2:CD006583.  Back to cited text no. 1
2.Jansen FW, Kolkman W, Bakkum EA, de Kroon CD, Trimbos-Kemper TC, Trimbos JB. Complications of laparoscopy: An inquiry about closed- versus open-entry technique. Am J Obstet Gynecol 2004;190:634-8.  Back to cited text no. 2
3.Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy a prospective multicentre observational study. Br J Obstet Gynaecol 1997;104:595-600.  Back to cited text no. 3
4.Aziz R. Advantages and disadvantages of operative endoscopy. In: Aziz R, Alvarez Murphy A, editors. Practical Manual of operative Laparoscopy. New York: Springer - Verlag; 1992. p. 1-8.  Back to cited text no. 4
5.Kadar N, Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol 1993;168:1493-5.  Back to cited text no. 5
6.Chiu CC, Lee WJ, Wang W, Wei PL, Huang MT. Prevention of trocar-wound hernia in laparoscopic bariatric operations. Obes Surg 2006;16:913-8.  Back to cited text no. 6
7.Mc Gurgan P, P' Donovan P. Optical versus as an entry technique. Endose 1999;8:379-92.  Back to cited text no. 7
8.Mettler I, Schmidt EH, Frank V, Semm K. Laparoscopic entry and its complications. Gynaecol Endose 1999;8:383-9.  Back to cited text no. 8
9.Noblett SE, Woodcock S. Port-site pyoderma gangrenosum - a rare complication of surgical trauma. Ann R Coll Surg Engl 2009;91:665-6.  Back to cited text no. 9
10.Wexner SD, Cohen SM. Port site metastases after laparoscopic colorectal surgery for cure of malignancy. Br J Surg 1995;82:295-8.  Back to cited text no. 10
11.Cirocco WC, Schwartzman A, Golub RW. Abdominal wall recurrence after laparoscopic colectomy for colon cancer. Surgery 1994;116:842-6.  Back to cited text no. 11
12.Shindholimath VV, Seenu V, Parshad R, Chaudhry R, Kumar A. Factors influencing wound infection following laparoscopic cholecystectomy. Trop Gastroenterol 2003;24:90-2.  Back to cited text no. 12
13.Richards C, Edwards J, Culver D, Emori TG, Tolson J, Gaynes R. The National nosocomial infections surveillance (NNIS) system, centers for disease control and prevention. Does using a laparoscopic approach to cholecystectomy decrease the risk of surgical site infection? Ann Surg 2003;237:358-62.  Back to cited text no. 13
14.Fuller J, Ashar BS, Carey-Corrado J. Trocar-associated injuries and fatalities: An analysis of 1399 reports to the FDA. J Minim Invasive Gynecol 2005;12:302-7.  Back to cited text no. 14
15.Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A, et al. The European association for endoscopic surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 2002;16:1121-43.  Back to cited text no. 15
16.Johnson WH, Fecher AM, McMahon RL, Grant JP, Pryor AD. VersaStep trocar hernia rate in unclosed fascial defects in bariatric patients. Surg Endosc 2006;20:1584-6.  Back to cited text no. 16
17.Berguer R. A technique for full thickness closure of laparoscopic trocar sites. J Am Coll Surg 1995;180:227-8.  Back to cited text no. 17
18.Carter JE. A new technique of fascial closure for laparoscopic incisions. J Laparoendosc Surg 1994;4:143-8.  Back to cited text no. 18
19.Targarona EM, Balagué C, Knook MM, Trías M. Laparoscopic surgery and surgical infection. Br J Surg 2000;87:536-44.  Back to cited text no. 19
20.Losanoff JE, Richman BW, Jones JW. Trocar-site hernia complicated by necrotizing fasciitis-case report and review of the literature. Hernia 2003;7:220-3.  Back to cited text no. 20
21.Den Hoed PT, Boelhouwer RU, Veen HF, Hop WC, Bruining HA. Infections and bacteriological data after laparoscopic and open gallbladder surgery. J Hosp Infect 1998;39:27-37.  Back to cited text no. 21
22.Colizza S, Rossi S, Picardi B, Carnuccio P, Pollicita S, Rodio F, et al . Surgical infections after laparoscopic cholecystectomy: Ceftriaxone vs ceftazidime antibiotic prophylaxis. A prospective study. Chir Ital 2004;56:397-402.  Back to cited text no. 22
23.Quilici PJ, Greaney EM, Quilici J, Anderson S. Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: Results of 509 repairs. Am Surg 1996;62:849-52.  Back to cited text no. 23
24.Azurin DJ, Go LS, Arroyo LR, Kirkland ML. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia. Am Surg 1995;61:718-20.  Back to cited text no. 24
25.Mayol J, Garcia-Aguilar J, Ortiz-Oshiro E, De-Diego Carmona JA, Fernandez-Represa JA. Risks of the minimal access approach for laparoscopic surgery: Multivariate analysis of morbidity related to umbilical trocar insertion. World J Surg 1997;21:529-33.  Back to cited text no. 25
26.Montz FJ, Holschneider CH, Munro MG. Incisional hernia following laparoscopy: A survey of the American association of gynecologic laparoscopists. Obstet Gynecol 1994;84:881-4.  Back to cited text no. 26
27.Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004;139:1248-56.  Back to cited text no. 27
28.Bruyère F, Sun J, Cosson JP, Kouri G. Incarceration of bowel through opening of a 5-mm port. J Endourol 2004;18:675-6.  Back to cited text no. 28
29.Ponsky JL. Complications of laparoscopic cholecystectomy. Am J Surg 1991;161:393-5.  Back to cited text no. 29
30.Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN, et al. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg 1996;224:609-20.  Back to cited text no. 30


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Follow-up of children who undergo an uncomplicated surgical procedure: A caregiver survey to determine satisfaction, family impact, and preferences for alternate follow-up.
Cindy Holland, Anna C. Shawyer
Journal of Pediatric Surgery. 2022;
[Pubmed] | [DOI]
Surgery in Practice and Science. 2022; : 100054
[Pubmed] | [DOI]
3 Ventral hernia repair with a hybrid laparoscopic technique
Nicholas Bell-Allen, Kate Swift, Nis-Julius Sontag, Nicholas O'Rourke
ANZ Journal of Surgery. 2022;
[Pubmed] | [DOI]
4 Vesicourachal diverticulum
G Mohamed, Z Ghani, N Lynn, M Masilamani, J Rowlands
The Annals of The Royal College of Surgeons of England. 2022;
[Pubmed] | [DOI]
5 Tips and Details for Successful Robotic Myomectomy: Single-Center Experience with the First 125 Cases
Lei Dou, Yi Zhang
Journal of Clinical Medicine. 2022; 11(11): 3221
[Pubmed] | [DOI]
6 Trocar-Related Safety Events in Minimally Invasive Surgical Procedures: Risks for Organ and Vascular Complications
Lea Gardner
Patient Safety. 2021; : 62
[Pubmed] | [DOI]
7 Assessment of Port Site Complications in Laparoscopic Surgery – A Prospective Descriptive Study from Western Odisha
Harekrishna Majhi, Tapan Kumar Nayak, Sheik Salman Raghib, Anand Seba Tirkey
Journal of Evidence Based Medicine and Healthcare. 2021; 8(24): 2106
[Pubmed] | [DOI]
8 Postprocedural Gastrointestinal Emergencies
Brian K. Parker, Sara Manning
Emergency Medicine Clinics of North America. 2021; 39(4): 781
[Pubmed] | [DOI]
Amish Wani, Ashwani Kumar Dalal, Usha Rani Dalal, Hari Rathi, Komal Komal, Akhil Garg
Journal of Evidence Based Medicine and Healthcare. 2019; 6(18): 1383
[Pubmed] | [DOI]
10 Umbilical port site keloid extending through rectus sheath
Guirgis Arsanios Awad,Paul Wilson
European Journal of Plastic Surgery. 2014; 37(6): 357
[Pubmed] | [DOI]
11 Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or Single Port?
Rishabh Sehgal,Ronan A. Cahill
Best Practice & Research Clinical Gastroenterology. 2014; 28(1): 81-96
[Pubmed] | [DOI]
12 Adult umbilical disorders in surgical practice - an experience from Kashmir
Salati, S.A., Rather, A.A.
Online Journal of Health and Allied Sciences. 2013; 12(4): 7
13 Advances in equine laparoscopy
D. A. Wilson
Equine Veterinary Education. 2013; 25(11): 578
[Pubmed] | [DOI]


Print this article  Email this article


© 2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04