Repair of parastomal hernias using polypropylene mesh

Parastomal hernia repair according to Modified Stapled Mesh Stoma Reinforcement Technique (mSMART): which are the results ?

INTRODUCTION

Parastomal hernia repair is a real surgical challenge because of the high rate of recurrence. The Stapled Mesh Stoma Reinforcement Technique (SMART) is a keyhole-like technique in which the mesh is stapled to the fascia using a circular mechanical stapler.

METHODS

A prospective study from January 2021 to February 2023 was conducted including all patients operated with the SMART technique. Primary endpoint was the recurrence rate during the follow-up. Secondary endpoints were reoperation, Surgical site Occurrence (SSO) and deep (mesh) surgical site infection (SSI) within 30 days postoperatively.

RESULTS

Sixteen patients operated on SMART procedures were included. The mean follow-up was 11.3 ± 9.2 months. The SSO rate was 18.7% (n = 3). A seroma was drained radiologically (IIIa), one haematoma was evacuated surgically (IIIb) and one patient presented a postoperative lesion of a ureter after a parastomal Bricker's hernia repair. In addition, there was one death due to multiple organ failure (V). There was no SSI. The recurrence rate was 57.1% during the follow-up.

CONCLUSION

This study shows disappointing results for this SMART technique, with a high recurrence rate.

Parastomal Hernia Repair

Parastomal hernias (PHs) are common and contribute to significant patient morbidity. Despite 45 years of evolution, mesh-based PH repairs continue to be challenging to perform and remain associated with high rates of postoperative complications and recurrences. In this article, the authors summarize the critical factors to consider when evaluating a patient for PH repair. The authors provide an overview of the current techniques for repair, including both open and minimally invasive approaches. The authors detail the mesh-based repair options and review the evidence for choice of mesh to use for repair.

A keyhole approach gives a sound repair for ileal conduit parastomal hernia

PURPOSE

The purpose of this study was to report and evaluate a laparoscopic surgical technique for the treatment of parastomal hernia (PSH) after ileal conduit urinary diversion aiming to minimize PSH recurrence and perioperative complications.

METHODS

We retrospectively evaluated all patients who underwent a PSH (after ileal conduit urinary diversion) repair at Addenbrookes Hospital, Cambridge. As a surgical approach, a laparoscopic repair with mesh was utilized in all cases. Subsequently, we performed a voluntary follow-up of the patients to evaluate long-term recurrence and complication rates. In addition, we conducted a reassessment of the cross-sectional imaging available.

RESULTS

Between November 2008 and December 2019, 27 patients underwent hernia repair due to a clinically significant hernia. Out of those patients, one suffered from a post-operative wound infection. In total 23 patients participated in the follow-up with a median follow-up period of 91 months. Follow-up examination revealed two cases of recurrent PSH (8.7% of patients followed up), four patients suffered from minor complications (14.8%).

CONCLUSION

Repair of PSH associated with ileal conduit is particularly scarce. Our surgical approach presents the only laparoscopic case series of an effective method for treating a PSH from an ileal conduit with a low complication and recurrence rate.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

INTRODUCTION

The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations.

METHODS

We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis.

RESULTS

Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial.

CONCLUSION

A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

Other Surgeries in Patients with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) will often require abdominal surgical intervention for indications not directly related to their IBD. Because these patients often have a history of multiple previous abdominal operations and/or ostomies, they are at increased risk for incisional and parastomal hernias. They may also have develop symptomatic cholelithiasis, chronic pain, or desmoid disease. All of these potentially surgical issues may require special consideration in the IBD population.

Diagnosis and Management of Parastomal Hernias

A 63-year-old woman with history of stage II rectal adenocarcinoma status postneoadjuvant chemoradiation and subsequent abdominoperineal resection presented with worsening bulge and inability to pouch stoma. CT scan revealed a 4-cm parastomal hernia. After discussion with the patient regarding management options, she elected to undergo repair of hernia defect. A robot-assisted laparoscopic parastomal hernia repair with synthetic mesh via the Sugarbaker technique was performed. After a short stay in the hospital, the patient recovered well and reported no recurrent symptoms.

Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure

Introduction

Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel.

Patients and Methods

Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects.

Results

Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma.

Conclusion

Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.

Surgical Management of Parastomal Hernias

Parastomal hernias are a common complication after ostomy formation that can require surgical repair when they become symptomatic. Operative planning and a thorough understanding of the anatomy of the abdominal wall are important. Simple fascial repair is associated with an unacceptably high recurrence rate and should be used as a temporary measure only. Stoma relocation has a high recurrence rate. Prophylactic mesh can and should be used. At this time, the use of mesh is considered the standard of care in the repair of parastomal hernias.

Systematic Review and Meta-analysis of Prophylactic Mesh During Primary Stoma Formation to Prevent Parastomal Hernia

BACKGROUND

Implantation of mesh at the time of stoma formation may reduce the rate of parastomal hernia. Until recently, the evidence has been limited to only a few small randomized controlled trials.

OBJECTIVE

We present an updated systematic review and meta-analysis to assess the effect of mesh prophylaxis on rates of parastomal hernia. We examine ongoing and unpublished trials via online registries and propose recommendations for future research.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2016 for published randomized controlled trials. Sixteen international trial registries were inspected for ongoing and unpublished trials.

STUDY SELECTION

Randomized controlled trials comparing mesh versus no mesh on the incidence of parastomal hernia after colostomy or ileostomy formation were selected.

MAIN OUTCOME MEASURES

The primary outcome measure was rate of parastomal hernia at least 12 months after stoma formation. Secondary outcomes included rates of stoma-related complications.

RESULTS

Of 3005 studies identified, 7 randomized controlled trials (432 patients) were eligible for inclusion in the final analysis. All were at high risk of bias. Mesh reduced the incidence of clinically detected parastomal hernia (10.8% vs 32.4%; p = 0.001) (risk ratio, 0.34; 95% CI, 0.18-0.65; I = 39%) and the rate of radiologically detected parastomal hernia (34.6% vs 55.3%; p = 0.01) (risk ratio, 0.61; 95% CI, 0.42-0.89; I = 44%). No increase in the incidence of stoma-related complications was observed with the use of prophylactic mesh. Results from ongoing and unpublished randomized controlled trials are expected, but few will report on alternative mesh types or surgical techniques.

LIMITATIONS

Heterogeneity of interventions, small patient populations, and a high risk of bias seen in all studies implicate cautious interpretation of the results.

CONCLUSION

Mesh prophylaxis at the time of stoma formation appears safe and effective in preventing parastomal hernia; however, limitations of the primary evidence justify larger, more rigorous randomized controlled trials.

Parastomal hernia: a growing problem with new solutions

Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias.

Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials

Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.

Systematic review of open techniques for parastomal hernia repair

Parastomal hernia formation is common following formation of an abdominal stoma, with the risk of subsequent incarceration, obstruction and strangulation. Current treatment options include non-operative management, stoma relocation and fascial repair with or without mesh. The purpose of this systematic review was to evaluate the effectiveness and safety of open mesh repair of a parastomal hernia and to compare open non-mesh fascial repair with mesh techniques of parastomal hernia repair. Electronic databases were searched for studies comparing the two surgical techniques in accordance with preferred reporting items for systematic reviews and meta-analyses. The primary outcome of the study was the comparison of recurrence rates of parastomal hernia for each technique. Secondary outcomes included comparison of mortality, wound infection, mesh infection and any other complication. Twenty-seven studies of parastomal hernia repair were included and divided into two subgroups for open mesh repair and non-mesh fascial repair. Non-mesh fascial repair resulted in a high recurrence rate (around 50%). Reported recurrence rates for mesh repair were substantially lower, at 7.9-14.8%, depending on the position of the mesh in relation to the abdominal fascia and the length of follow-up. Morbidity and mortality did not differ significantly between the techniques used to repair a parastomal hernia. This study shows that mesh repair of a parastomal hernia is safe and significantly reduces the rate of recurrence compared with sutured repair, which should only be used in exceptional circumstances. There is insufficient evidence to determine which mesh technique (onlay, sublay or underlay) is most successful in terms of recurrence rates and morbidity.

Parastomal hernia repair

Occurrence of parastomal hernia is considered a near inevitable consequence of stoma formation, making their management a common clinical dilemma. This article reviews the outcomes of different surgical approaches for hernia repair and describes in detail the laparoscopic Sugarbaker technique, which has been shown to have lower recurrence rates than other methods. Also reviewed is the current literature on the impact of prophylactic mesh placement during ostomy formation.

The persistent challenge of parastomal herniation: a review of the literature and future developments

AIM

The aim of this review article was to outline current evidence relating to the treatment and prevention of parastomal herniation with a view to guide surgeons dealing with patients potentially affected by this complication.

METHOD

Medline and PubMed databases were searched using the keywords 'parastomal hernia/herniation', 'stoma hernia/herniation' and 'stoma complications'. Evidence was obtained from randomized and non-randomized studies. Case reports and articles not written in English were excluded. Qualitative assessment of all included studies was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence.

RESULTS

The search revealed a total of 228 publications of which 115 fulfilled the selection criteria. Stoma formation through the rectus muscle is complicated by parastomal herniation in up to 50% of cases. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. The 'Sugarbaker' technique appears to be superior to the 'keyhole' technique when a laparoscopic approach is used. Prophylactic mesh reinforcement of the stoma trephine appears to reduce the herniation rate to approximately 15% and is accompanied by a decrease in symptomatic hernias requiring repair without any difference in stoma-related morbidity.

CONCLUSION

Large prospective controlled trials are required to compare surgical techniques of stoma formation in reducing the incidence of parastomal herniation. Despite limited evidence, routine prophylactic mesh reinforcement of the stoma trephine should be offered to all patients undergoing permanent stoma formation.

Surgical techniques for parastomal hernia repair: a systematic review of the literature

BACKGROUND

Parastomal hernias are a frequent complication of enterostomies that require surgical treatment in approximately half of patients. This systematic review aimed to evaluate and compare the safety and effectiveness of the surgical techniques available for parastomal hernia repair.

METHODS

Systematic review was performed in accordance with PRISMA. Assessment of methodological quality and selection of studies of parastomal hernia repair was done with a modified MINORS. Subgroups were formed for each surgical technique. Primary outcome was recurrence after at least 1-year follow-up. Secondary outcomes were mortality and postoperative morbidity. Outcomes were analyzed using weighted pooled proportions and logistic regression.

RESULTS

Thirty studies were included with the majority retrospective. Suture repair resulted in a significantly increased recurrence rate when compared with mesh repair (odds ratio [OR] 8.9, 95% confidence interval [CI] 5.2-15.1; P < 0.0001). Recurrence rates for mesh repair ranged from 6.9% to 17% and did not differ significantly. In the laparoscopic repair group, the Sugarbaker technique had less recurrences than the keyhole technique (OR 2.3, 95% CI 1.2-4.6; P = 0.016). Morbidity did not differ between techniques. The overall rate of mesh infections was low (3%, 95% CI 2) and comparable for each type of mesh repair.

CONCLUSIONS

Suture repair of parastomal hernia should be abandoned because of increased recurrence rates. The use of mesh in parastomal hernia repair significantly reduces recurrence rates and is safe with a low overall rate of mesh infection. In laparoscopic repair, the Sugarbaker technique is superior over the keyhole technique showing fewer recurrences.

Laparoscopic paracolostomy hernia repair: a retrospective case series at a tertiary care center

BACKGROUND

Paracolostomy hernias are one of the most common complications of stomas. Primary repair is associated with a high rate of recurrence. The choice is between mesh-reinforced repair of the defect and relocation of the stoma to another position. The laparoscopic approach seems attractive, as it is minimally invasive, requires shorter hospitalization, and the entry is through a noncontaminated part of the abdomen.

STUDY DESIGN

This study consists of a case series of 9 patients with paracolostomy hernia, of which 2 had recurrent hernias. All patients presenting with nonobstructed parastomal hernias at our clinic between October 2006 and October 2009 are included in this series. Two patients that presented with obstruction are not included. We describe our technique for this surgery using the laparoscopic approach and discuss the outcomes.

RESULTS

Nine patients with permanent colostomies in the left lumbar quadrant after abdominoperineal resection presented with parastomal hernias of varying durations and were subjected to laparoscopic repair. The average operating time was 112 minutes. All the patients were mobilized postoperatively and were discharged by 48 hours. None of the patients have reported any complication, including recurrence.

CONCLUSIONS

Laparoscopic repair of paracolostomy hernia using a technique involving intracorporeal suturing of defect followed by reinforcement by a tissue-separating mesh is safe and feasible.

Randomized, controlled, prospective trial of the use of a mesh to prevent parastomal hernia

BACKGROUND

The prevalence of terminal parastomal hernia (PH) after colostomy placement may be as high as 50%. The effect of the PH may range from discomfort to life-threatening complications. Surgical procedures for repairing PH are difficult to perform and present a high-failure rate.

OBJECTIVE

To reduce the incidence of PH by implanting a lightweight mesh in the sublay position.

MATERIAL AND METHODS

Randomized, controlled, prospective study. Patients were scheduled for permanent end colostomy surgery to treat cancer of the lower third of the rectum, performed by the same colorectal surgery team. An Ultrapro lightweight mesh was inserted in the sublay position in the study group. Using simple randomization, the sample size required was estimated to be 27 per group. Patients were followed-up clinically and radiologically with abdominal computed tomography by an independent clinician and a radiologist who were all blind to the aims of the study, 1 month and every 6 months after surgery.

RESULTS

: The groups were homogeneous in terms of their clinical and demographic characteristics. Surgical time and postoperative morbidity were similar in the 2 groups. Mortality was 0. No mesh intolerance was reported. In the clinical follow-up (median: 29 months, range: 13-49), 11/27 (40.7%) hernias were recorded in the control group compared with 4/27 (14.8%) in the study group (P = 0.03). Abdominal computed tomography identified 14/27 (44.4%) hernias in the control group compared with 6/27 (22.2%) in the study group (P = 0.08).

CONCLUSIONS

Parastomal placement of a mesh reduces the appearance of PH. The technique is safe, well-tolerated, and does not increase morbidity rates.

Parastomal hernia repair using cross-linked porcine dermis: report of a case

Parastomal hernia is not an uncommon complication after colostomy or ileostomy formation, but it may have serious consequences, such as intestinal obstruction and strangulation. Thus, the surgeon must repair the parastomal hernia using a technique that minimizes the chance of recurrence and complications. This case report describes a novel method of parastomal hernia repair using cross-linked acellular porcine dermal collagen matrix, a new biological material suitable for hernia repair.

Parastomal hernias

The incidence of parastomal hernias is probably 30% to 50%. Suture repair of a parastomal hernia or relocation of the stoma results in a high recurrence rate, whereas with mesh repair recurrence rates are lower. Several mesh repair techniques are used in open and laparoscopic surgery, but randomized trials comparing various techniques and with long-term follow-up are needed for better evidence.

Laparoscopic paracolostomy hernia mesh repair

Paracolostomy hernia is a common occurrence, representing a late complication of stoma surgery. Different surgical techniques have been proposed to repair the wall defect, but the lowest recurrence rates are associated with the use of mesh. We present the case report of a patient in which laparoscopic paracolostomy hernia mesh repair has been successfully performed.

Role of biological mesh in surgical treatment of paracolostomy hernias

BACKGROUND

Paracolostomy hernia is a frequent complication of intestinal stoma. Its correction can be made through relocation of the colostomy or by keeping it in place and performing abdominal wall reinforcement through direct suturing with or without a prosthesis.

METHOD

Results of surgical treatment of paracolostomy hernias were analyzed in 22 patients who underwent surgery in our hospital during the past 15 years, with or without biological mesh (bovine pericardium). All patients had terminal colostomies after abdominoperineal excision of the rectum.

RESULTS

In 15 (68.2%) patients, hernia correction was made by maintaining the colostomy in place, in 2 of them (9.1%) without reinforcement, and in the other 13 (59.1%) through reinforcement of the aponeurosis with biological mesh. In the 7 (31.8%) other patients, hernia correction was accomplished by relocation of the colostomy. The mean follow-up period was 50.2 months. Recurrence was observed in 3 (13.6%) patients after a median of 16 months post-correction.

CONCLUSION

Paracolostomy hernia remains a surgical challenge due to its high recurrence rate. Primary repair using a prosthesis of biological material may be preferable since muscle-aponeurotic weakness is frequently observed.

Parastomal hernia repair using the lateral approach

OBJECTIVE

To review the results of repairing a parastomal hernia after ileal conduit formation, using the lateral approach.

PATIENTS AND METHODS

We retrospectively assessed 18 patients (9%) who developed a parastomal hernia, from 211 who had an ileal conduit created between 1982 and 2001; 15 had a surgical repair using a lateral incision.

RESULTS

All 15 patients resumed a normal diet 1 day after surgery; the median (range) hospital stay was 4 (2-14) days. In two patients with a large hernia and difficult repair the stomas became ischaemic and required refashioning. Only one of these two patients required complete conduit replacement. The median (range) follow-up was 15 (1-72) months. A recurrence of the hernia was recorded in one grossly overweight patient.

CONCLUSION

The lateral approach obviates the need for laparotomy and stomal relocation, and enhances a quick return of bowel function and early recovery. However, extra care is needed in managing the very large and difficult hernia, to avoid compromising the ileal conduit. The success and complication rates of the current series are within acceptable limits and this technique can be included in the options for managing parastomal hernia.

Mesh herniorrhaphy during elective colorectal surgery

The management of large ventral hernias in patients undergoing elective colorectal surgery is controversial considering the reluctance to use a mesh during a clean-contaminated case. We retrospectively reviewed the charts of all patients having undergone at our institution any colorectal surgery along with ventral hernia repair with mesh as identified by the ICD-9 codes between 1997 and 2003. Three patients underwent incisional mesh herniorrhaphy along with elective colorectal surgery, including a right hemicolectomy, a colostomy closure, and a diverting colostomy. Hernia size varied between 330 and 1,243 cm(2). All hernias were repaired using polypropylene mesh in an onlay fashion. Average operative time was 199 min. Two patients developed postoperative wound infection, one of them requiring incision and drainage of a part of the wound. One patient developed skin necrosis of the lower aspect of his incision requiring skin excision and open wound. All open wounds granulated well and healed by secondary intention despite presence of exposed mesh. Therefore prosthetic ventral hernia repair using polypropylene mesh can be performed concomitant to elective colorectal operations, thus avoiding another laparotomy. The incidence of wound complications is, however, high but does not usually require mesh excision.

In Situ Mesh Repair of Parasternal Hernias

Options for the repair of parastomal hernias include contralateral transposition or in situ repair. The latter can be accomplished either primarily or with prosthetic mesh. Concerns with mesh include possible gut erosion and infection. Recurrence rates in the literature are dismal regardless of technique. We retrospectively reviewed our experience with this problem focusing on in situ repairs. We identified 9 patients who underwent 10 in situ repairs. Of these, 6 were women, average age was 69.4 years, and stomas had been constructed for cancer in 6, inflammatory bowel disease in 2, and incontinence in 1. Eight patients had colostomies; one had an ileostomy. All patients were symptomatic from their hernias. Repairs were performed an average of 8 years after stoma construction. Hernia repair was performed transabdominally in four and through a parastomal incision in six. Complications included hematoma formation requiring evacuation in one and delayed resumption of oral intake secondary to nausea and cramps in three. Of the 9 initial repairs, 1 recurred (11%) and was repaired without subsequent failure. No mesh erosions or wound infections have occurred. This technique is safe and may be preferable to contralateral placement of the stoma.

Incisional hernia repair

Incisional ventral hernias are a common problem encountered by surgeons, with over 100,000 repairs being performed annually in the United States. Although many predisposing factors for incisional ventral hernia are patient-related, some factors such as type of primary closure and materials used may reduce the overall incidence of incisional ventral hernia. With the advent of prosthetic meshes being used for incisional ventral hernia repair, the recurrence rate has dropped to approximately 10%. More recently, with the development of prosthetic mesh that is now safe to place intraperitoneally, the recurrence rate has dropped to under 5%. The current controversies that exist for incisional ventral hernia repair are which approach to use (open versus laparoscopic) and what type of fixation (partial- versus full-thickness abdominal muscular/fascial wall) is necessary to stabilize the position of the mesh while tissue ingrowth occurs. During the next decade the answers to these controversies should be available in the surgical literature.

Parastomal hernia

BACKGROUND

Parastomal hernia following formation of an ileostomy or colostomy is common. This article reviews the incidence of hernia, the technical factors related to the construction of the stoma that may influence the incidence, and the success of the different methods of repair.

METHODS

A literature search using the Medline database was performed to locate English language articles on parastomal hernia. Further articles were obtained from the references cited in the literature initially reviewed.

RESULTS

Parastomal hernia affects 1.8-28.3 per cent of end ileostomies, and 0-6.2 per cent of loop ileostomies. Following colostomy formation, the rates are 4.0-48.1 and 0-30.8 per cent respectively. Site of stoma formation (through or lateral to rectus abdominis), trephine size, fascial fixation and closure of lateral space are not proven to affect the incidence of hernia. The role of extraperitoneal stoma construction is uncertain. Mesh repair gives a lower rate of recurrence (0-33.3 per cent) than direct tissue repair (46-100 per cent) or stoma relocation (0-76.2 per cent).

CONCLUSION

The incidence of parastomal hernia is between 0 and 48.1 per cent, depending on the type of stoma and length of follow-up. No technical factors related to the construction of the stoma have been shown to prevent herniation. If repair is required, a prosthetic mesh technique should be considered. Further randomized clinical trials (particularly of extraperitoneal stoma construction) are needed.

Is parastomal hernia repair with polypropylene mesh safe?

BACKGROUND

Concern over the safety of polypropylene mesh in parastomal hernia repairs has led some to avoid its use. We reviewed our rate of complications and outcomes with polypropylene mesh.

METHODS

From January 1988 through May 2002, 58 patients underwent parastomal hernia repair with polypropylene mesh. After closure of the fascia, the stoma was pulled through the center of the mesh, which was placed either above or below the fascia. Multivariate analysis was performed to determine independent predictors for the development of complications.

RESULTS

There were 31 end colostomies, 24 end ileostomies, and 3 loop transverse colostomies. Mean follow-up with 50.6 months. Overall complications related to the polypropylene mesh was 36% (recurrence 26%, surgical bowel obstruction 9%, prolapse 3%, wound infection 3%, fistula 3%, and mesh erosion 2%). None of the patients had extirpation of their mesh. Complications were significantly associated with younger age (59.6 versus 67 years, P = 0.04). Cancer patients with stomas had fewer complications (P = 0.02, odds ratio 0.34). Inflammatory bowel disease, stomal type, mesh location, urgent procedures, steroid use, and surgical approaches were not significantly associated with an increased complication rate. Of the 15 patients with recurrence, 7 underwent successful repair for an overall success rate of 86%.

CONCLUSIONS

Parastomal hernia repair with polypropylene mesh is safe and effective.

Laparoscopic parastomal hernia repair

Parastomal hernia is a common complication of ostomy construction. The morbidity and recurrence rates associated with repair can be quite high. Among the various approaches to repair, the lowest recurrence rates are associated with the use of mesh. We report a case in which a parastomal hernia was repaired laparoscopically. By employing this minimally invasive approach, our patient avoided the morbidity associated with laparotomy for intraperitoneal mesh placement.

Preperitoneal approach to parastomal hernia with coexistent large incisional hernia

OBJECTIVE: To assess the outcome of preperitoneal mesh repair of complex incisional herniae incorporating a stoma and large parastomal hernia. METHODS: From 1994 to 1998, symptomatic patients who had repair of combined incisional hernia and parastomal hernia were reviewed. Body mass index, co-morbidity, length of hospital stay, patient satisfaction and outcomes were recorded. RESULTS: Ten patients (seven females and three males), mean age 62 (range 48-80) years underwent primary repair. All had significant comorbidities (ASA grade 3) and mean body mass index was 31.1 (range 20-49). Median hospital stay was 15 (range 8-150) days. Complications were of varying clinical significance (seroma, superficial infection, major respiratory tract infection and stomal necrosis). There were no recurrences after a mean follow up of 54 (range 22-69) months. CONCLUSION: The combination of a parastomal hernia and generalised wound dehiscence is an uncommon but difficult problem. The application of the principles of low-tension mesh repair can provide a satisfactory outcome and low recurrence rate. This must be tempered by recognition of the potential for significant major postoperative complication.

Reparo de grandes hérnias ostomais com permanência do estoma, utilizando tela de polipropileno

OBJETIVO: Descrever a experiência dos autores na correção de grandes hérnias ostomais , apresentando os resultados obtidos através da utilização de técnica preconizada pelo serviço. MÉTODO: Foram analisados , retrospectivamente , seis casos de grandes hérnias ostomais (>10cm), no período de 1982 a 1999, sendo dois pacientes do sexo masculino e quatro do feminino, com média etária de 60 anos. Foram observadas duas hérnias paraostomais e quatro hérnias periostomais. RESULTADOS: Três pacientes foram submetidos à técnica preconizada pelos autores, com uso de tela de polipropileno e permanência do estoma, outros três pacientes foram submetidos à correção das hérnias com mudança do local da ostomia. Não houve recorrência na amostra estudada após acompanhamento que variou de um a cinco anos. CONCLUSÕES: A técnica proposta possibilita a manutenção da ostomia em seu sítio primário, reforça a parede, previne a recidiva herniária e o prolapso da ostomia.

Surgical treatment of parastomal hernia complicating sigmoid colostomies

PURPOSE

Parastomal hernia is a common late complication of colostomy. Surgical approach to the repair of parastomal hernia is controversial. Results of surgical treatment are disappointing. The aim of this study was to assess the outcome of surgical treatment of parastomal hernia.

METHOD

This article reports a retrospective review of those patients who had undergone a surgical treatment of parastomal hernia complicating sigmoid colostomy. The indications, surgical procedures, complications, and outcome were carefully studied.

RESULTS

There were 43 surgical treatments of parastomal hernia. Sixteen underwent simple local repair; 25 stomas were relocated, and 2 were locally repaired with mesh. Overall recurrence was 18 of 40 (45 percent). Recurrences for fascial repair and stoma relocation were 6 of 13 (46 percent) and 10 of 25 (40 percent), respectively. Stoma relocation could be accomplished without formal laparotomy in 19 of 25 cases. Incisional hernia occurred in only 2 of these 25 relocations.

CONCLUSION

Fascial repair alone can be performed for symptomatic small hernias because of its advantage of minimal morbidity. Stoma relocation without formal laparotomy can be advocated for larger hernias. A combination of local resite together with mesh reinforcement may be the alternative for further improvement of results.

Is laparotomy mandatory for parastomal hernia repair?

OBJECTIVE

A parastomal hernia is an incisional hernia at the site of an intestinal stoma. The incidence varies, as do techniques for repair and their associated rates of success. The aim of this study was to evaluate the methods of parastomal hernia repair and their outcome.

PATIENTS AND METHODS

Between 1988 and 1998, 33 patients who underwent elective parastomal hernia repair were identified by the use of a computerized database. Information was collected on the indication and type of reparative procedure, as well as any morbidity or recurrence, post-operative complications and recurrence. The operative procedures performed included reanastomosis and ipsilateral and contralateral relocation with hernia repair. Additional data were collected on whether a laparotomy was required or mesh was placed.

RESULTS

The commonest operation was relocation without laparotomy or mesh (36%), followed by laparotomy still without mesh (21%); the overall recurrence rate was 9% (3/33) at a mean follow up of 55.2 months (range 10-108 months).

CONCLUSION

Parastomal hernia repair without laparotomy or mesh is a safe and effective method of repair.

Improving the reinforcement of parastomal tissues with Marlex mesh: laboratory study identifying solutions to stomal aperture distortion

PURPOSE

Parastomal hernia formation commonly complicates permanent stomas and represents a significant and frequently recurrent management problem, regardless of the method of repair. Prosthetic material reinforcement of parastomal tissues offers the best results. However, problems with unravelling of mesh fibers along cut margins leading to aperture enlargement and hernia recurrence may occur. Raised intra-abdominal pressure in the early postoperative period before incorporation of the mesh into surrounding tissues may result in hernia formation if the aperture size in the mesh increases.

METHODS

Assessment of the physical properties of Marlex mesh was performed in a materials testing laboratory, using standardized tests to simulate the stresses imposed on in situ mesh.

RESULTS

Holes cut in Marlex mesh were found to enlarge and distort at loads simulating intra-abdominal pressure changes. Reinforcement with a polypropylene pursestring suture was found to stabilize the periaperture mesh fibers and maintain the original area throughout tensions at least double maximal intra-abdominal pressures. Distensibility of intact sheets of mesh was found to vary by up to 100 percent, depending on the direction of the applied tension, and thus, mesh orientation in hernia repair has major implications.

CONCLUSION

We propose that if mesh is used to reinforce abdominal wall tissues and is cut or fashioned to size, then the cut margins must be reinforced if the intended dimensions and functional integrity of the mesh are to be maintained.

Parastomal hernia repair: modified thorlakson technique, reinforced by polypropylene mesh

The use of mesh repairs in parastomal hernias has recently been the subject of controversy. We describe a modified Thorlakson technique that incorporates an incomplete circumferential mesh to reinforce the fascial repair. In this preliminary report five cases have been operated on without any serious complications. A comprehensive literature review found that a total of 72 cases have been reported by various authors. Failure rates caused by recurrence or mesh-related sepsis amounted to 8.3 percent. In comparison with results for stoma relocations and nonprosthetic in-situ fascial repairs, mesh repairs have the lowest recurrence rates.

Laparoscopic repair of paracolostomy hernia

Paracolostomy hernia is a common complication of stoma creation. Operative repair is indicated in about 15% of cases, through several surgical approaches. We describe a laparoscopic technique used to repair a large symptomatic paracolostomy hernia in a 69-year-old woman almost 20 years after abdominoperineal resection. The laparoscopic approach to such a hernia is feasible, safe, and logical, as it combines the advantages of mesh reinforcement with those of endoscopic repair.

Complications of abdominal stoma surgery

PURPOSE

This study was undertaken to review and summarize the complications of ileostomy and colostomy creation and subsequent closure.

METHODS

The English-language medical literature for at least the past 15 years was reviewed comprehensively.

RESULTS

Complications of surgery for the creation of end, loop, and "end loop" stomas are presented. Technical factors, which might influence complication rates, are discussed. Optimal management of ostomy complications is presented, especially for peristomal hernias. Similarly, techniques and complications for stoma closure are analyzed.

CONCLUSIONS

Stoma creation is not a trivial undertaking; careful surgical technique minimizes complications (which are relatively frequent), and promotes good ostomy function. Peristomal hernias are difficult to cure permanently. The morbidity of ileostomy and colostomy closure is also appreciable.