Parastomal Hernia: A Retrospective Nationwide Cohort Study Comparing Different Techniques with Long-Term Follow-Up

Comparison of different mesh placement techniques for parastomal hernia repair: an updated systematic review and network meta-analysis

PURPOSE

We performed a network meta-analysis to evaluate the comparative effectiveness of different mesh placement techniques in parastomal hernia repair on clinical and patient-reported outcomes.

METHODS

A comprehensive search was conducted in PubMed, Scopus, Cochrane, and Web of Science for articles published until January 2025, focusing on recurrence rates, cumulative complication rates, operative time, length of hospital stay, surgical site infection rate, and Postoperative bowel obstruction rate. The risk of bias was assessed with ROBINS-I and RoB 2. GRADE assessment was performed to evaluate the body of evidence.

RESULTS

Twenty studies were included in the meta-analysis. Hybrid 3D had lower rates of hernia recurrence than Keyhole (OR 0.20, 95% CI: 0.07-0.59) and had lower rates of surgical site infections than Sugarbaker (OR 0.25, 95% CI: 0.07-0.90). Sandwich had the highest ranking with the lowest recurrence rate (P-score: 0.8188), followed by Hybrid 3D. Hybrid 3D was associated with lower rates of cumulative complications than the keyhole technique (OR 0.33, 95% CI 0.15-0.74) and compared with the Sugarbaker technique (OR 0.35, 95% CI:0.17-0.75). No statistically significant differences were observed between techniques for postoperative bowel obstruction, operative time, or length of hospital stay. However, Hybrid 3D and Sandwich consistently ranked higher for favorable outcomes across these metrics.

CONCLUSIONS

These findings suggest that Hybrid 3D and Sandwich techniques offer superior outcomes regarding hernia recurrence and cumulative complications. Further high-quality randomized trials are required to confirm these results.

Hybrid Open Anterior and Laparoscopic Repair Using Self-Gripping Mesh for Parastomal Hernia Following Ileal Conduit With Extensive Intra-abdominal Adhesions: A Case Report

Parastomal hernia (PSH) is the protrusion of visceral organs through an abdominal wall defect adjacent to a stoma and is one of the major complications following cystectomy and ileal conduit (IC) formation. We report a case of hybrid open anterior and laparoscopic repair using self-gripping mesh for a PSH following IC, complicated by extensive intra-abdominal adhesions. An 89-year-old man presented with recurrent episodes of small bowel obstruction (SBO) caused by PSH following IC. The patient had undergone total cystectomy with IC for urinary bladder cancer 30 years prior and had been hospitalized nine times for SBO due to PSH. The patient was referred for surgical treatment. Computed tomography revealed protrusion of the small bowel through a 10 × 7 cm hernia orifice around the IC. Considering the symptomatic PSH with a persistent risk of SBO, laparoscopic repair was planned. Laparoscopic exploration revealed extensive adhesions of the small bowel to the hernia orifice and IC, extending to the pelvis. The IC was also widely attached to the anterior abdominal wall, preventing visual assessment of the contralateral side of the conduit. Therefore, an additional transverse skin incision was made laterally and caudally to the stoma. The defect was closed anteriorly under direct vision with interrupted transfascial sutures and reinforced by onlay mesh placement using a trimmed (15 × 12 cm) self-gripping mesh (ProgripTM, Medtronic). The postoperative course was uneventful. At the 15-month follow-up, the patient was in good physical condition without hernia recurrence or SBO, except for intermittent episodes of urinary obstruction requiring drainage. Hybrid open anterior and laparoscopic repair using self-gripping mesh may be considered a surgical option for PSH following IC with extensive intra-abdominal adhesions around the stoma.

Initial and recurrent management of parastomal hernia after cystectomy and ileal conduit urinary diversion: a 10 year single-center experience

PURPOSE

The management of parastomal hernia following cystectomy and ileal conduit diversion is challenging due to its specific nature and a high recurrence rate, yet is poorly described.

METHODS

We retrospectively searched the clinical data warehouse of our center for patients who had primary parastomal hernia repair following cystectomy and ileal conduit diversion. The primary endpoint was recurrence of parastomal hernia; secondary endpoints were postoperative complications and surgical management of recurrences.

RESULTS

From January 1st 2012 to January 1st 2022, 35 patients were included in the study, 13 patients (37.1%) were operated with the Keyhole technique and 22 patients (62.9%) with the Sugarbaker technique. The median follow-up was 24 months. The main complication was urinary tract infection, in 6 patients (17.4%). Postoperative complications were severe in 4 patients (11.4%), 3 (8.6%) for prosthesis extraction due to infection. Ninety-day mortality was null. Eight patients (22.9%) had a symptomatic recurrence of parastomal hernia leading to a second surgery, 4 patients (30.7%) in the Keyhole group and 4 patients (18.2%) in the Sugarbaker group. Surgical management of recurrences involved repair without synthetic mesh in 4 patients (50%) due to difficult adhesiolysis, leading to a third surgery for 3 patients (37.5%).

CONCLUSION

The high rates of recurrence observed with the Keyhole technique, in particular, but also with the Sugarbaker technique, suggest that these techniques should no longer be used for the repair of parastomal hernia after ileal conduit urinary diversion. New preventive and curative approaches need to be explored to improve the surgical management of parastomal hernia.

Early outcomes of robotic modified retromuscular Sugarbaker technique for end colostomy parastomal hernia repair

AIM

The modified retromuscular Sugarbaker or Pauli technique is a technique for parastomal hernia repair, which requires the dissection of the retromuscular space and a transversus abdominis release for stoma lateralization and placement of a retromuscular mesh. Given the limited evidence regarding the robotic approach to this technique, this study aims to evaluate the outcomes of this newly introduced procedure, focusing on the rate of 30-day complications and recurrence rates.

METHODS

Retrospective case series report. Patients included underwent an elective robotic modified retromuscular Sugarbaker technique for the repair of a parastomal hernia associated with an end colostomy. All surgeries were performed at a tertiary referral center from September 2020 to December 2023.

RESULTS

A total of 21 patients underwent a robotic modified retromuscular Sugarbaker in our study. The parastomal hernias operated on were classified according to the European Hernia Society as 9.5% (2/21) type I, 52.4% (11/21) type II, 23.8% (5/21) type III, 14.3% (3/21) type IV. Early complications observed included 14.3% (3/21) seroma, 9.5% (2/21) surgical site infection, 19% (4/21) postoperative ileus, and one case of large bowel obstruction due to colitis (4.8%), which was managed conservatively. No Clavien-Dindo grade III complications were reported. The overall recurrence rate was 9.5% (2/21) with a median follow-up of 12.5 months (IQR: 3.9-21.3). Both recurrences occurred during the early phases of the learning curve and were possibly attributed to insufficient lateralization of the stoma.

CONCLUSION

Robotic modified retromuscular Sugarbaker for parastomal hernia repair is a challenging procedure with promising early outcomes.

Surgeons' opinions and concerns regarding prophylactic mesh placement when conducting a permanent ileo- and colostomy A survey among 172 surgeons in Germany, Switzerland, and Austria

Background

Prophylactic mesh placement when creating a permanent colostomy was recommended by the 2017 European Hernia Society guidelines on the prevention and treatment of parastomal hernias (GPTPH2017). The extent of this recommendation is under debate based on the long-term data from clinical trials. Our aim was to conduct a survey of surgeons revealing perspectives and concerns regarding GPTPH2017 and to discuss their concerns.

Methods

From January 2023 to September 2023 a survey among surgeons of Germany, Switzerland and Austria was conducted. The questionnaire addressed demographic data of the participants, information on work experience/location, number of elective permanent colo- and ileostomies, and opinions on the recommendation of GPTPH2017 for prophylactic mesh placement.

Results

A total of 172 surgeons from Germany, Austria and Switzerland answered the questionnaire and 59 of them stated professional experience of 20-30 years. Most of the surgeons (n = 51, 31.3%) worked in a primary care hospital. A total of 112 participants were familiar with the GPTPH2017. Sixty-five surgeons (40%) stated that they never conduct a prophylactic mesh placement when creating an elective permanent colostomy (rarely, n = 44 (26.7%). Seven participants always place a mesh (4.2%, missing data: 7). Main concerns regarding prophylactic mesh placement was the concern of surgeons about wound infection (n = 107, 67.7%) and lack of evidence (n = 65, 41.1%). For some participants the GPTPH2017 is seen to be industry-driven with low evidence, too old and leading to overtreatment.

Conclusions

The main reason for not placing a prophylactic mesh when conducting a permanent colostomy was the risk of wound infection.

Robotic parastomal hernia repair: A single-center cohort study

Parastomal hernia is a common occurrence following stoma construction, necessitating surgical intervention in symptomatic cases. This study presents a comprehensive analysis of Robotic-Assisted Parastomal Hernia Repair (r-PSHR), utilizing the Da Vinci Xi™ Surgical System. Retrospective analysis was conducted on patients undergoing r-PSHR at a high-volume center. Surgical variables, complications, and recurrence rates were assessed. The primary technique involved a modified Sugarbaker intraperitoneal onlay mesh. Eighty-six patients underwent r-PSHR, predominantly females (59.3%), with mean age 60.8 years. Mean BMI was 31.0. Most patients were classified as ASA 2 (31.4%) or ASA 3 (65.1), with 64.6% having no prior PSH repair. Index procedures primarily involved laparoscopic colonic resections (27.8%) and open abdominoperineal resections (27.8%). Parastomal hernias were mainly associated with end ileostomy (50%) and end colostomy (47.7%). A hybrid modification was required in 22.1% of cases, with only one conversion to open repair. Mean operative time was 257 min. Thirty-day morbidity was 40.7% and includes ileus (24.4%), deep surgical-site infections (7.0%), acute kidney injury (5.8%), and sepsis (5.8%). Grade IIIB complications occurred in 5.8% of cases. Thirty-day readmissions were observed in 19.8% of cases. There were five cases (5.8%) of recurrence within 15 months post-surgery. This study highlights the effectiveness of r-PSHR in managing parastomal hernia. R-PSHR shows promising outcomes with an acceptable post-operative occurrence profile and a favorable recurrence rate.

Stoma Complications

Stoma-related complications are among the most common sources of perioperative morbidity in colorectal surgery. Complications can occur intraoperatively, in the immediate postoperative period, or even months to years after stoma creation. Although some will require urgent surgical intervention, most are treated nonoperatively with a combination of education, appliance adjustment, and behavioral intervention. Optimal management of stoma complications nearly always requires a multidisciplinary team approach, including surgeons, enterostomal therapists, and other allied health professionals, depending on the specific situation. Patients with a functional stoma should be expected to be able to do anything that patients without a stoma can do with minimal exceptions. The treatment of stoma complications therefore centers on improving stoma function and maximizing quality of life. Although timely and comprehensive intervention will result in the resolution of most stoma complications, there is no substitute for preoperative planning and meticulous stoma creation.

Parastomal Hernia Prevention Using Funnel-Shaped Intra-Abdominal Mesh Compared to No Mesh: The Chimney Randomized Clinical Trial

Importance

Prophylactic placement of a mesh has been suggested to prevent parastomal hernia. Evidence to support this practice is contradictory.

Objective

To determine whether funnel-shaped permanent synthetic parastomal mesh is effective and safe in parastomal hernia prevention.

Design, Setting, and Participants

The Chimney Trial was a randomized single-blinded multicenter trial conducted in 4 hospitals in Finland and 1 in Sweden from February 2019 and September 2021. Of 439 patients with rectal adenocarcinoma undergoing either laparoscopic or robotic-assisted abdominoperineal resection or the Hartmann procedure, 143 were enrolled in the trial, 135 received their allocated intervention, and 121 were analyzed at 12-month follow-up. Data were analyzed from December 2023 to May 2024.

Intervention

In the intervention group, a permanent colostomy was created with a funnel-shaped intraperitoneal mesh and compared to a control group with a stoma without the mesh.

Main Outcome and Measure

The primary end point was the incidence of computed tomography (CT)-confirmed parastomal hernia 12 months after surgery.

Results

There were 68 patients (mean [SD] age, 68.7 [11.6] years; 36 [53% male and 32 [47%] female) who received the intended allocation in the mesh group and 67 (mean [SD] age, 66.4 [11.7] years; 48 [72%] male and 19 [28%] female) who received the intended allocation in the control group. CT scans were available for 58 patients in the mesh group and 59 patients in the control group at the 12-month follow-up. CT scans confirmed parastomal hernia in 6 of 58 patients (10%) in the mesh group compared to 22 of 59 patients (37%) in the control group (difference, 27%; 95% CI, 12-41; P < .001). Clinical parastomal hernia as a secondary outcome was recorded in 1 of 60 patients (2%) in the mesh group compared to 27 of 61 (43%) in the control group (difference, 41%; 95% CI, 29-55; P < .001). The number of patients with Clavien-Dindo class II ileus was 23 (35%) in the mesh group compared to 11 (17%) in the control group (difference, 18%; 95% CI, 3-32; P = .006). Only slight differences between the groups were detected in other stoma-related complications, readmissions, operative time, surgical site infections, reoperations, and quality of life.

Conclusions and Relevance

In this study, funnel-shaped parastomal mesh prevented a significant number of parastomal hernias without predisposing patients to mesh- or stoma-related complications during 12-month follow-up. The results of this study suggest the funnel-shaped mesh is a feasible option to prevent parastomal hernia.

Trial Registration

ClinicalTrials.gov Identifier: NCT03799939.

Robotic Pauli repair of parastomal hernia

BACKGROUND

Robotic retro-muscular mesh repair of parastomal hernia (PH) is possible with transversus abdominis release. The aim of this study is to report mid-term results with this method.

METHODS

Patients who underwent surgery for PH were enrolled in a prospective study. Patients with concomitant midline hernia also underwent Rives repair. Polypropylene meshes with an absorbable buffer mesh were used in the retro-muscular pocket-except PTFE was chosen for inflammatory bowel disease patients. Follow-up was by telephone and physical examination and CT if suspicion of complication.

RESULTS

Of the 56 included ostomy patients, 44 had colostomies, 10 had ileostomies, and two had urostomies. Thirty-nine percent had a concomitant hernia, and 25% had recurrent PH. The mean operating time without accessory repair was 156 min (SD 37), and with accessory repairs 220 min (SD 62). One bowel lesion and one vascular injury to the stoma occurred, prompting intraoperative stoma revision without postoperative morbidity. Postoperative complications ensued in 12 patients (23%). One patient had stoma necrosis after 3 weeks and the stoma was relocated. One patient had a mesh infection, 3 patients temporary ileus, one patient hypovolemic renal failure, and two patients experienced a flare-up of their Crohn's Disease. One parastomal abscess was drained percutaneously. The median postoperative stay was 3 days (1-21; mean 3.7 days), and the readmission rate was 8.9%. The recurrence rate at mean and median 24 months follow-up is 5.4%, two in ileostomy patients and one colostomy patient with unaltered bulging where CT shows a relatively large prolapse and recorded as a failure.

CONCLUSION

Robotic Pauli repair has shown promising results. However, repair fails of PH at small bowel ostomies with short mesentery. ePauli/TAR is now the preliminary choice for eligible patients at our site. Comparative studies with the intraperitoneal mesh standard are needed.

Open Retromuscular Sugarbaker vs Keyhole Mesh Placement for Parastomal Hernia Repair: A Randomized Clinical Trial

Importance

Durable parastomal hernia repair remains elusive. There is limited evidence comparing the durability of the open retromuscular Sugarbaker and keyhole mesh configurations.

Objective

To determine if the open retromuscular Sugarbaker mesh placement technique would lower parastomal hernia recurrence rates.

Design, Setting, and Participants

In this single-center, randomized clinical trial, 150 patients with a permanent stoma and associated parastomal hernia who were candidates for open retromuscular parastomal hernia repair were enrolled and randomized from April 2019 to April 2022 and followed up for 2 years.

Interventions

Following intraoperative assessment to determine the feasibility of either technique, enrolled patients were randomized to receive either retromuscular Sugarbaker or keyhole synthetic mesh placement.

Main Outcomes and Measures

The primary outcome was parastomal hernia recurrence at 2 years. Secondary outcomes included mesh-related complications, wound complications, reoperations, as well as patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at 1 year and 2 years.

Results

A total of 150 patients were randomized, and with 91% follow-up at 2 years, there were 13 (17%) parastomal hernia recurrences in the retromuscular Sugarbaker arm and 18 (24%) in the keyhole arm (adjusted risk difference, -0.029; 95% CI, -0.17 to 0.153, and adjusted risk ratio, 0.87; 95% CI, 0.42 to 1.69). There were no statistically significant differences between the Sugarbaker and keyhole groups regarding reoperations for recurrence (2 vs 7, respectively), nonhernia intra-abdominal pathology (4 vs 10, respectively), stoma necrosis (1 vs 0, respectively), mesh-related complications (4 vs 1, respectively), patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at any time point.

Conclusions and Relevance

In the setting of open parastomal hernia repair, a retromuscular Sugarbaker mesh placement technique was not superior to a keyhole configuration 2 years after repair. Further innovation is necessary to improve parastomal hernia repair outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03972553.

Repair of Parastomal Hernias

Parastomal hernias are an inevitable consequence of ostomy formation and their repairs remain a challenge to many surgeons. With multiple systems of classification and a multitude of techniques for hernia repair ranging from suture to mesh repair, the literature remains sparse with regards to the optimal method of repair. The authors describe the most commonly adopted techniques, discuss preventative measures, and review the current literature in the context of perioperative outcomes and hernia recurrence.

Comparison of the 3-D mesh and Sugarbaker repair for parastomal hernia: a single center experience in China

Parastomal hernias (PSH) are difficult to manage and associated with high rates of postoperative recurrence and complications. Sugarbaker and three-dimensional (3-D) mesh repair are commonly used methods for the surgical treatment of PSH. However, the efficacy and safety of these surgical techniques have not been adequately compared. Patients with PSH who received 3-D mesh or Sugarbaker repair at our center from August 2012 to May 2023 were included. We retrospectively analyzed their demographic data and postoperative outcomes. The primary outcome measure was the recurrence rate at 1-year follow-up. A total of 86 patients were enrolled, involving 53 in the 3-D mesh (62%) group and 33 in the Sugarbaker (38%) group. Most cases (73%) involved were the laparoscopic approach. The recurrence rate at 1-year follow-up was 15% (eight cases) in the 3-D mesh group and 24% (eight cases) in the Sugarbaker group, with no statistical significance (P = 0.29). Additionally, no differences were observed between the 3-D mesh and Sugarbaker groups in the length of hospitalization or in short- and long-term complications. Sugarbaker and 3-D mesh repair have similar clinical efficacy in the surgical treatment of PSH. Further randomized controlled trials are required to confirm these results.Trial registration number.This study was retrospectively registered at clinicaltrials.gov (NCT06077318).

Perioperative and extended outcomes of patients undergoing parastomal hernia repair following cystectomy and ileal conduit

PURPOSE

To report perioperative and long-term postoperative outcomes of cystectomy patients with ileal conduit (IC) urinary diversion undergoing parastomal hernia (PSH) repair.

METHOD

We reviewed patients who underwent cystectomy and IC diversion between 2003 and 2022 in our center. Baseline variables, including surgical approach of PSH repair and repair technique, were captured. Multivariable Cox regressionanalysis was performed to test for the associations between different variables and PSH recurrence.

RESULTS

Thirty-six patients with a median (IQR) age of 79 (73-82) years were included. The median time between cystectomy and PSH repair was 30 (14-49) months. Most PSH repairs (32/36, 89%) were performed electively, while 4 were due to small bowel obstruction. Hernia repairs were performed through open (n=25), robotic (10), and laparoscopic approaches (1). Surgical techniques included direct repair with mesh (20), direct repair without mesh (4), stoma relocation with mesh (5), and stomarelocation without mesh (7). The 90-day complication rate was 28%. In a median follow-up of 24 (7-47) months, 17 patients (47%) had a recurrence. The median time to recurrence was 9 (7-24) months. On multivariable analysis, 90-day complication following PSH repair was associated with an increased risk of recurrence.

CONCLUSIONS

In this report of one of the largest series of PSH repair in the Urology literature, 47% of patients had a recurrence following hernia repair with a median follow-up time of 2 years. There was no significant difference in recurrence rates when comparing repair technique or the use of open or minimally invasive approaches.

Repair of parastomal hernias with the intraperitoneal funnel meshes IPST-R and IPST

The treatment of parastomal hernias (PSH) represents a major challenge in hernia surgery. Various techniques have been reported with different outcomes in terms of complication and recurrence rates. The aim of this study is to share our initial experience with the implantation of the DynaMesh-IPST-R and -IPST, intraperitoneal funnel meshes made of polyvinylidene fluoride (PVDF). This is a retrospective observational cohort study of patients treated for PSH between March 2019 and April 2023 using the chimney technique with the intraperitoneal funnel meshes IPST-R or IPST. The primary outcome was recurrence and the secondary outcomes were intraoperative and postoperative complications, the latter assessed using the Clavien-Dindo classification. A total of 21 consecutive patients were treated with intraperitoneal PVDF funnel meshes, 17 with IPST-R and 4 with IPST. There were no intraoperative complications. Overall, no complications occurred in 61.9% (n = 12) of the patients. Major postoperative complications (defined as Clavien-Dindo ≥ 3b) were noted in four cases (19.0%). During the mean follow-up period of 21.6 (range 4.8-37.5) months, one patient (4.8%) had a recurrence. In conclusion, for the treatment of parastomal hernias, the implantation of IPST-R or IPST mesh has proven to be efficient, easy to handle, and very safe. In particular, the low recurrence rate of 4.8%, which is in line with the current literature, is convincing. However, a larger number of patients would improve the validity of the results.

Parastomal hernia prevention with an intraperitoneal prophylactic 3D-funnel mesh: review of the technique and middle-term results

PURPOSE

Parastomal hernia (PH) stands out as a prevalent complication following end colostomies, significantly affecting patients' quality of life. Various surgical strategies, predominantly involving prophylactic mesh deployment, have been explored with variable outcomes. This study details our experience and mid-term outcomes utilizing a funnel-shaped mesh.

METHODS

A single-center, prospective, non-randomized, observational study examined consecutive patients undergoing colorectal surgery with end colostomy, incorporating a 3D-funnel mesh from January 2019 to December 2021 (PM group). A historical cohort of patients with end colostomy without prophylactic mesh served as the comparison (C group). Postoperative morbidity within 30 days was documented, and clinical examinations and radiological tests were employed for parastomal hernia diagnosis during follow-up.

RESULTS

Seventy-two patients participated, with thirty-four in the PM group and thirty-eight in the C group. The PM group experienced 16 postoperative complications, unrelated to the mesh, while the C group recorded 20 complications (p = 0.672). Median follow-up was 22.06 months for the PM group and 63.18 months for the C group. The PM group exhibited a lower parastomal hernia incidence during follow-up (8.8%) compared to the C group(68.4%) (p < 0.001).

CONCLUSION

Prophylactic use of a 3D-funnel mesh appears effective in reducing parastomal hernia incidence in the short and mid-term, without an associated increase in postoperative morbidity.

Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach

Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.

Repair of parastomal hernia after Bricker procedure: retrospective consecutive experience of a tertiary center

BACKGROUND

Ileal conduit parastomal hernias (ICPHs) are frequent after radical cystectomy with ileal conduit urinary diversion, but their management is debated. This study aimed to review the results of ICPH repair according to Sugarbaker or Sandwich techniques, with special interest in ICPH recurrence and urological complications.

METHODS

The authors reviewed a consecutive series of patients undergoing ICPH repair between January 2014 and December 2020. Primary endpoints were ICPH recurrences at clinical exam and cross-sectional abdominal computed tomography (CT) scans. Secondary endpoints were any other complications possibly related to the ICPH repair.

RESULTS

Twenty-three patients underwent ICPH repair surgery (16 Sugarbaker and 7 Sandwich techniques) during the study period. Sixteen patients underwent a primary laparoscopic approach. All but one patient underwent at least one abdominal CT during the follow-up. Median clinical and CT scan follow-up times were 57 and 50.5 months, respectively. Clinical and CT ICPH recurrence rates were 4.5% and 13% at 5 years, respectively. Eighteen patients (78%) suffered no urological complications during the follow-up period, but three patients (13%) needed redo surgery on the urinary ileal conduit.

CONCLUSION

The modified Sugarbaker or Sandwich techniques might be considered as promising techniques for ICPH repair with a low rate of recurrence. The urological complications, and particularly the ileal conduit-related issues, need to be evaluated in further studies. Controlled and prospective data are required to compare the Sugarbaker and Sandwich techniques to the Keyhole approach for ICPH repairs.

The clinical applications of D-type parastomal hernia repair surgery

OBJECTIVE

This study investigated the use of a modified laparoscopic repair of paraostomy hernia technique, called "D-Type parastomal hernia repair surgery" which combines abdominal wall and extraperitoneal stoma reconstruction, in patients with parastomal hernia (PSH) following colorectal stoma surgery. The aim was to determine whether D-type parastomal hernia repair surgery is a promising surgical approach compared to the traditional laparoscopic repair technique (Sugarbaker method) for patients with PSH.

METHODS

PSH patients were selected and retrospectively divided into two groups: the study group underwent D-type parastomal hernia repair, while the control group underwent laparoscopic Sugarbaker repair. Clinical data from both groups were analyzed.

RESULT

Compared to control group (n = 68), the study group undergoing D-type stoma lateral hernia repair had significant increase in total operative time (98.82 ± 12.37 min vs 124.61 ± 34.99 min, p < 0.001). The study group also showed better postoperative stoma bowel function scores in sensory ability, frequency of bowel movements, and clothing cleanliness without a stoma bag (p = 0.037, 0.001, 0.002). The treatment cost was significantly higher in the control group (3899.97 ± 260.00$ vs 3215.91 ± 230.03$, p < 0.001). The postoperative recurrence rate in the control group was 26.4%, while in the study group, it was 4.3%, with a significant statistical difference (p = 0.024). In terms of long-term postoperative complications, the study group had an overall lower incidence compared to the control group (p = 0.035). Other parameters showed no significant differences between the two groups.

CONCLUSION

The study suggests that D-type parastomal hernia repair surgery is a safe and feasible procedure. Compared to traditional surgery, it can reduce the recurrence of lateral hernia, improve postoperative stoma bowel function, and save medical resources.

Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland

BACKGROUND

In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs).

METHODS

All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis.

RESULTS

A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002).

CONCLUSION

Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.

Prophylactic mesh does not prevent parastomal hernia in long-term: Meta-analysis and trial sequential analysis

BACKGROUND

Previous randomized clinical trials, systematic reviews, and meta-analyses evaluating parastomal hernia prevention with mesh placement during end colostomy formation have reported contradictory results. This review aimed to assess the efficacy of this strategy in long-term follow-up according to the latest available data.

METHODS

Medline, EMBASE, Cochrane Library, Web of Science, and Google Scholar were searched. Randomized clinical trials were included if they compared mesh with no mesh during initial end colostomy creation in adult patients to prevent parastomal hernia with a follow-up longer than 2 years. A meta-analysis was performed to evaluate parastomal hernia incidence (primary outcome), parastomal hernia repair rate, and mortality. Subgroup analysis included surgical approach and mesh position, and trial sequential analysis was performed.

RESULTS

Eight randomized clinical trials involving 537 patients met the inclusion criteria. Based on long-term follow-up, the incidence of parastomal hernia was not reduced when a prophylactic mesh was placed (relative risk = 0.68 [95% confidence interval:0.46-1.02]; I2 = 81%, P =.06). The parastomal hernia repair rate was low; however, no difference was found between the groups (relative risk = 0.90 [95% confidence interval:0.51-1.56]; I2 = 0%; P = .70), and no difference was detected between the groups when mortality was assessed (relative risk = 1.03 [95% confidence interval: 0.77-1.39]; I2 = 21%; P = .83). Subgroup analyses did not show differences according to the surgical approach or mesh position used. Regarding trial sequential analysis, an optimal information size was not achieved.

CONCLUSION

Prophylactic mesh placement during end colostomy formation does not prevent parastomal hernia in the long term. The parastomal hernia repair rate and mortality rate did not vary between the included groups. Heterogeneity among the included randomized clinical trials might restrict the reliability of the results.

Robotic Retromuscular (Recurrent) Parastomal Hernia Repair (r-Pauli-Repair) With Synthetically Reinforced Biological Mesh; Technique, Early Experience, and Short-Term Follow-Up

Introduction: Parastomal hernia repair remains a challenge. We describe a robotic retromuscular non-keyhole mesh repair using a synthetically reinforced biological mesh (Ovitex) for the repair of complex and/or recurrent parastomal hernia and technical modifications we made along the way to improve our technique. Methods: All patients underwent the described retromuscular parastomal hernia repair. Data was collected in a database and a retrospective analysis was performed on direct postoperative results and early follow-up. Results: Eleven patients underwent the operation. Median follow-up was 12 months. Median LOS was 6 days. Two recurrences occurred. One patient suffered postoperative hematoma and skin necrosis, which healed completely, but did lead to a recurrence. One patient had a significant seroma, which subsided without intervention. Both recurrences were reoperated, and a local repair was performed. Conclusion: This paper is the first to describe a modified robotic Pauli repair for complex and recurrent parastomal hernia, using a synthetically reinforced biological mesh. Results are satisfying so far, especially considering the complexity of the cases.

Analysis of recurrence and risk factors in laparoscopic sandwich technique for parastomal hernia repair

INTRODUCTION

Parastomal hernias are frequent and highly recurrent. The sandwich technique is a combination of the keyhole and Sugarbaker techniques, using a double intraperitoneal mesh. The objective of this study was to assess the outcomes of the sandwich technique, specifically focusing on recurrence rates.

MATERIALS AND METHODS

Observational retrospective study conducted in two tertiary referral centers in Catalonia, Spain. All consecutive patients who underwent parastomal hernia repair using the sandwich technique between 1st January 2016 and 31st December 2021 were included.

RESULTS

A total of 38 patients underwent the laparoscopic sandwich technique for parastomal hernia repair. The overall recurrence rate was 7.9% (3/38), with a median follow-up of 39 months (IQR: 12.3-56.5). According to the EHS classification for parastomal hernia, there were 47.4% (18/38) type I defects, 10.5% (4/38) type II defects, 28.9% (11/38) type III defects, and 13.2% (5/38) type IV defects. The used mesh was predominantly TiMesh® (76.3%; 29/38), followed by DynaMesh® IPOM (23.7%; 9/38). Patients with recurrence exhibited higher rates of seroma, hematoma, surgical site infection, and one case of early recurrence attributed to mesh retraction. Consequently, postoperative complications emerged as the primary risk factor for hernia recurrence.

CONCLUSION

The sandwich technique demonstrated recurrence rates consistent with those reported in the existing literature.

Laparoscopic parastomal hernia repair: keyhole, Sugarbaker, sandwich, or hybrid technique with 3D mesh? An updated systematic review and meta-analysis

PURPOSE

Parastomal hernia is the most common complication after stoma formation with an incidence that approaches 50% at 2 years postoperatively. In the last decade, different approaches of minimally invasive procedures have been proposed for the treatment of parastomal hernia. Nevertheless, the superiority of one technique over the others remains still unclear. Our objective was to update and systematically analyze current state of research concerning the postoperative outcomes of the four most prevalent minimally invasive techniques.

METHODS

A systematic literature search of three databases (Medline, Scopus, Google Scholar) was undertaken for articles published from January 2015 to November 2022. Fifteen studies from a previous meta-analysis on the topic were included.

RESULTS

Thirty-three studies incorporating 1289 total patients were deemed eligible for inclusion in the final analysis. The keyhole technique was associated with the highest incidence of postoperative complications and recurrences (31.3% and 24.1%, respectively), followed by the Sugarbaker technique (27.6% and 9%, respectively). Operative time was among the lowest in patients operated with the 3D mesh technique, while patients undergoing the keyhole technique experienced the shortest cumulative length of hospital stay (6 days).

CONCLUSION

Each technique demonstrates a unique profile of effectiveness offset by the propensity towards developing postoperative complications. While no conclusive evidence on the optimal technique exist to date, newer minimally invasive techniques show promising results, albeit based on limited data. The future of parastomal hernia repair seems to rely on a highly individualized approach, tailored to the distinctive characteristics of both the hernia and the patient.

Keyhole Versus Sugarbaker Mesh Configuration in Parastomal Hernia Repair: A Systematic Review and Meta-analysis

BACKGROUND

Parastomal hernia repairs (PHRs) are often complex and challenging, even for experienced abdominal wall surgeons. Although the ideal therapeutic option in the setting of a parastomal hernia is to restore intestinal continuity, this is often not feasible, and numerous techniques have been described for PHR. Current guidelines recommend using mesh for elective PHR, but there is a scarcity of evidence comparing different PHR techniques. We aimed to report a meta-analysis comparing the outcomes of the "Sugarbaker" and "Keyhole" mesh configuration in PHR.

METHODS

A literature search of PubMed, Embase, Scopus, and Cochrane Library databases was performed to identify studies comparing Sugarbaker and Keyhole mesh configuration in PHR. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.

RESULTS

A total of 3247 studies were screened, and 27 were fully reviewed. Ten studies and 632 patients were included in the meta-analysis. Three hundred five patients (48.3%) with Keyhole and 327 patients (51.7%) with Sugarbaker mesh configuration. Four hundred thirty-three patients (68.5%) underwent laparoscopic PHR with intraperitoneal onlay mesh. Sugarbaker mesh configuration was associated with lower hernia recurrence compared with Keyhole (odds ratio: 0.39; 95% CI: 0.19-0.83; P = 0.01; I2 = 46%). No differences were seen in overall complications, reoperations, stoma outlet obstruction, mesh infection, and postoperative bleeding.

CONCLUSION

PHR with Sugarbaker mesh configuration is associated with decreased hernia recurrence compared with Keyhole and had similar rates of overall complications, reoperations, stoma outlet obstruction, mesh infection, and postoperative bleeding.

Parastomal hernia prevention with permanent mesh in end colostomy: failure with late follow-up of cohorts in three randomized trials

PURPOSE

Short-term results have been reported regarding parastomal hernia (PH) prevention with a permanent mesh. Long-term results are scarce. The objective was to assess the long-term PH occurrence after a prophylactic synthetic non-absorbable mesh.

METHODS

Long-term data of three randomized controlled trials (RCTs) were collected. The primary outcome was the detection of PH based exclusively on a radiological diagnosis by computed tomography (CT) performed during the long-term follow-up. The Kaplan-Meier method was used for the comparison of time to diagnosis of PH according to the presence of mesh vs. no-mesh and the technique of mesh insertion: open retromuscular, laparoscopic keyhole, and laparoscopic modified Sugarbaker.

RESULTS

We studied 121 patients (87 men, median age 70 years), 82 (67.8%) of which developed a PH. The median overall length of follow-up was 48.5 months [interquartile range (IQR) 14.4-104.9], with a median time until PH diagnosis of 17.7 months (IQR 9.3-49.0). The survival analysis did not show significant differences in the time to development of a PH according to the presence or absence of a prophylactic mesh neither in the overall study population (log-rank, P = 0.094) nor in the groups of each technique of mesh insertion, although according to the surgical technique, a higher reduction in the appearance of PH for the open retromuscular technique was found (log-rank, P = 0.001).

CONCLUSION

In the long-term follow-up placement of a non-absorbable synthetic prophylactic mesh in the context of an elective end colostomy does not seem effective for preventing PH.

Outcomes of parastomal hernia repair after national centralization

BACKGROUND

In 2010, it was decided to centralize parastomal hernia repairs to five specialized hernia centres in Denmark to improve outcomes. The aim of this nationwide cohort study was to evaluate whether centralization of parastomal hernia repairs has had an impact on outcomes. Specifically, readmission, reoperation for complication, and operation for recurrence were analysed before and after centralization.

METHODS

By merging clinical and administrative outcome data from the Danish Hernia Database with those from the Danish National Patient Registry, all patients undergoing parastomal hernia repair in Denmark from 1 January 2007 to 31 December 2018 were included. Centralization was defined as having at least 70 per cent of procedures were performed at one of the five national centres. Readmission, reoperation, and recurrence rates for emergency and elective repairs were evaluated before and after centralization.

RESULTS

In total, 1062 patients were included. Median follow-up was 992 days. Overall, the centralization process took 7 years. For elective repairs, the readmission, reoperation, mortality, and recurrence rates were comparable before and after centralization, but more patients overall and more patients with co-morbidity were offered surgery after centralization. For emergency repairs, there was a significant reduction in rates of reoperation (from 44.9 per cent (48 of 107) to 23 per cent (14 of 62); P = 0.004) and mortality (from 10.3 per cent (11 of 107) to 2 per cent (1 of 62); P = 0.034) after centralization.

CONCLUSION

Centralization led to more elective operations and better outcomes when emergency repair was needed. Centralization of parastomal hernia repair led to more patients receiving elective repair and significantly improved outcomes after emergency repair.

Sugarbaker Versus Keyhole Repair for Parastomal Hernia: a Systematic Review and Meta-analysis of Comparative Studies

INTRODUCTION

Parastomal hernia is a debilitating complication of stoma creation. Parastomal hernia repair with mesh reduces recurrence rates in open and laparoscopic settings. Recent comparative studies conflict with previously pooled data on optimal mesh repair technique. The objective of this study is to examine parastomal hernia recurrence rates after Sugarbaker and keyhole repairs by performing an updated systematic review and meta-analysis of comparative studies.

METHODS

A systematic review of PubMed, MEDLINE, EMBASE, the Cochrane database, SCOPUS, and the PROSPERO registry was performed according to PRISMA 2020 guidelines (PROSPERO ID: CRD42021290483). Studies comparing parastomal hernia recurrences after Sugarbaker and keyhole repairs were included. Studies with overlapping patient cohorts (duplicate data), non-comparative studies, studies that did not report the primary outcome of interest, and studies not in the English language were excluded. Study bias was assessed using the Newcastle-Ottawa scale. Pooled mean differences (MD), odds ratios (OR), and risk ratios (RR) with 95% confidence intervals (CI) were calculated. Heterogeneity was assessed using the I² statistic. Forest plots and funnel plots were generated. Study quality was analyzed using MINORS. Additional subgroup analysis of modern studies was performed.

RESULTS

Ten comparative studies published between 2005 and 2021 from 5 countries were included for analysis comprising 347 Sugarbaker repairs and 246 keyhole repairs. There were no differences in patient age, sex, or BMI between the groups. There was no difference between the groups regarding surgical site infection (OR 0.78; CI 0.31-1.98; P = 0.61) or post-operative bowel obstruction (OR 0.76; CI 0.23-2.56; P = 0.66). Sugarbaker repairs were significantly less often associated with parastomal hernia recurrence when compared to keyhole repairs (OR 0.38; CI 0.18-0.78; P = 0.008). There was no significant heterogeneity among the studies comparing parastomal hernia recurrence (I² = 32%; P = 0.15). Quality analysis revealed a median MINORS score of 11 (range 6-16). Subgroup analysis of studies performed after the previously published pooled analysis (2015-2021) revealed no significant difference in parastomal hernia recurrence between the two groups (OR 0.58; CI 0.24-1.38; P = 0.22) with a significant subgroup effect (P = 0.05).

CONCLUSIONS

Though there were lower rates of parastomal hernia recurrence with Sugarbaker repairs on overall analysis, this phenomenon disappeared on subgroup analysis of modern studies. Randomized controlled trials with contemporary cohorts would help further evaluate these repairs and minimize potential bias.

Robotic hernia surgery IV. English version : Robotic parastomal hernia repair. Video report and preliminary results

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

[Robotic hernia surgery IV. German version : Robotic parastomal hernia repair. Video report and preliminary results]

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

Parastomal hernias after cystectomy and ileal conduit urinary diversion: surgical treatment and the use of prophylactic mesh: a systematic review

BACKGROUND

Parastomal hernia after ileal conduit urinary diversion is an underestimated and undertreated clinical entity, which heavily impairs patients' quality of life due to symptoms of pain, leakage, application or skin problems. As for all gastrointestinal stomata the best surgical repair technique has yet to be determined. Thereby, surgery for ileal conduit parastomal hernias poses some specific perioperative challenges. This review aims to give an overview of current evidence on the surgical treatment of parastomal hernia after cystectomy and ileal conduit urinary diversion, and on the use of prophylactic mesh at index surgery in its prevention.

METHODS

A systematic review was performed according to PRISMA-guidelines. The electronic databases Embase, PubMed, Cochrane Library, and Web of Science were searched. Studies were included if they presented postoperative outcomes of patients undergoing surgical treatment of parastomal hernia at the ileal conduit site, irrespective of the technique used. A search was performed to identify additional studies on prophylactic mesh in the prevention of ileal conduit parastomal hernia, that were not identified by the initial search.

RESULTS

Eight retrospective case-series were included for analysis, reporting different surgical techniques. If reported, highest complication rate was 45%. Recurrence rates varied highly, ranging from 0 to 80%. Notably, lower recurrence rates were reported in studies with shorter follow-up. Overall, available data suggest significant morbidity after the surgical treatment of ileal conduit parastomal hernias. Data from five conference abstracts on the matter were retrieved, and systematically reported. Regarding prophylactic mesh in the prevention of ileal conduit parastomal hernia, 5 communications were identified. All of them used keyhole mesh in a retromuscular position, and reported on favorable results in the mesh group without an increase in mesh-related complications.

CONCLUSION

Data on the surgical treatment of ileal conduit parastomal hernias and the use of prophylactic mesh in its prevention is scarce. Given the specific perioperative challenges and the paucity of reported results, more high-quality evidence is needed to determine the optimal treatment of this specific surgical problem. Initial results on the use of prophylactic mesh in the prevention of ileal conduit parastomal hernias seem promising.

Modified Laparoscopic Sugarbaker Repair of Parastomal Hernia With a Totally Extraperitoneal Technique

Purpose: Many patients develop a parastomal hernia within the first 2 years of stoma formation, and even surgical repair is associated with high recurrence rates. An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia; it is unknown whether a totally extraperitoneal technique (TEP) is feasible. Here we describe a laparoscopic TEP approach using a modified Sugarbaker method for the repair of parastomal hernia.

Methods: Seven patients underwent parastomal hernia repair. The retrograde puncture technique was used to create the extrapneumoperitoneum, and the peritoneum was separated with a laparoscopic TEP approach; the mesh was placed using a modified Sugarbaker technique.

Results: All patients had an oncologic etiology for stoma creation. The mean (±SD) size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm². The mean operative time was 195.5 ± 20.7 min and average length of hospital stay after surgery was 4.8 ± 2.1 days. One patient had intraoperative subcutaneous emphysema. The average follow-up time was 8.5 ± 2.7 months; mild pain occurred in 2 patients, 3 experienced seroma formation (with no special treatment required), and 1 had early intestinal obstruction (which was treated with conservative care). There was no hernia recurrence, wound complications, or infections of the surgical site or mesh during follow-up.

Conclusion: A laparoscopic TEP technique is technically challenging but feasible. Modified laparoscopic Sugarbaker repair of a parastomal hernia with the TEP technique is safe and effective, although the recurrence rate and late complications require confirmation in more cases with long-term follow-up.