Relationship between stoma creation route for end colostomy and parastomal hernia development after laparoscopic surgery

Extraperitoneal Colostomy Versus Transperitoneal Colostomy After Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to compare extraperitoneal colostomy (EPC) with transperitoneal colostomy (TPC) after laparoscopic abdominoperineal resection (APR) for rectal cancer regarding postoperative complications.

METHOD

A literature search was performed on PubMed, Ovid, and Cochrane Databases for studies comparing EPC with TPC after laparoscopic APR for rectal cancer. The last search was performed on June 4, 2024. The primary outcome was the incidence of parastomal hernia. The Review Manager (version 5.3) was used for data analysis.

RESULTS

A total of 9 studies with 1002 patients were included in this meta-analysis. Among the enrolled literatures, one was randomized clinical trials, and others were retrospectively case-control designed. EPC showed significant efficiency in preventing parastomal hernia (P<0.001, OR=0.16, 95% CI: 0.09-0.28, I2=0%). Besides, the results indicated that the EPC group was associated with significantly less incidence of stoma retraction (P=0.02, OR=0.23, 95% CI: 0.06-0.81, I2=0%), stoma prolapse (P=0.002, OR=0.18, 95% CI: 0.06-0.54, I2=0%), and total stoma-related complications (P<0.001, OR=0.50, 95% CI: 0.33-0.74, I2=26%). In addition, no significant difference was observed between the 2 groups in terms of the total operative time or the time for colostomy creation.

CONCLUSION

Current data demonstrated the significant efficiency of EPC in preventing parastomal hernia after laparoscopic APR for rectal cancer. Besides, the clinical safety and feasibility of EPC were also indicated. The EPC procedure could be widely recommended for permanent colostomy in clinical practice.

Systematic review and meta-analysis comparing extraperitoneal and transperitoneal routes of colostomy-related complications

BACKGROUND

Complications associated with stomas-including parastomal hernia (PSH), prolapse, mucocutaneous separation, and stoma retraction-provide considerable postoperative challenges for colostomy patients. Selecting between extraperitoneal colostomy (EPC) and transperitoneal colostomy (TPC) pathways is therefore essential for mitigating these complications.

AIM

To analyze the existing data regarding the efficacy of EPC compared to TPC in reducing stoma-related complications post-colostomy.

METHODS

PubMed, Google Scholar, EMBASE, MEDLINE, and the Cochrane Library were adopted to uncover pertinent papers in which EPC and TPC approaches were compared. We then conducted a meta-analysis using RevMan 5.4.1.

RESULTS

Both laparoscopic (Lap) and open approaches showed a reduced incidence of PSH in EPC relative to TPC (P < 0.00001 and P = 0.02 respectively). In addition, Lap EPC depicted a lesser incidence of prolapse, mucocutaneous separation, and stoma retraction (P = 0.007, P = 0.03, and P = 0.01, respectively) compared to Lap TPC. However, EPC and TPC did not differ with respect to operation time, blood loss, edema, ischemia, necrosis, or infection after the LAP approach.

CONCLUSION

The extraperitoneal approach may provide benefits in minimizing some stoma-related problems such as PSH, prolapse, mucocutaneous separation, and stoma retraction after colostomy surgery.

The safety of laparoscopic extraperitoneal colostomy in the introductory phase: A prospective observational study by the Kanagawa Yokohama Colorectal Cancer Study Group (KYCC) 1804

PURPOSE

To assess the incidence of parastomal hernia in the introductory phase following laparoscopic extraperitoneal colostomy.

METHODS

The subjects of this observational study were 30 patients who underwent laparoscopic extraperitoneal sigmoid colostomy between April 2019 and November 2020. We evaluated the incidence of parastomal hernia over 2 years and the time required for stoma creation.

RESULTS

Parastomal hernia was diagnosed in five patients (17.2%), which was a higher incidence than that reported previously (0-13.3%). An exploratory analysis using the LASSO logistic regression model identified obesity (body mass index ≥25 kg/m2) and postoperative wound dehiscence as risk factors for parastomal hernia. The mean stoma creation time was 23.6 min, with >80% of cases completed within 30 min.

CONCLUSION

Laparoscopic extraperitoneal colostomy can be adopted successfully, even in centers without prior experience. However, the incidence of parastomal hernia in this study was slightly higher than reported previously. Obese patients had longer stoma creation times and a higher incidence of parastomal hernia.

Risk factors for parastomal hernia after abdominoperineal resection of rectal cancer

Purpose

To investigate risk factors associated with the formation of parastomal hernia after Miles operation, and to provide scientific evidence for the prevention and treatment of parastomal hernia.

Methods

Clinical data from 205 patients with rectal cancer undergoing Miles operation in the Department of General Surgery, Affiliated Hospital of Xuzhou Medical University between May 2016 and May 2021 were analyzed retrospectively. Fourteen potential factors were selected and analyzed by single factor analysis and two element logistic regression analysis for their potential relationship to incidence of parastomal hernia.

Results

49 cases of parastomal hernia occurred among 194 patients during follow-up (incidence 25.26%). Univariate analysis showed that age, thickness of subcutaneous abdominal fat, BMI, and stoma pathway were related to the formation of post-surgical parastomal hernia (P < 0.05). Two element logistic regression analysis showed that advanced age, thickness of subcutaneous abdominal fat, BMI > 25 kg/m2, and transperitoneal surgical approach were independent risk factors for the formation of parastomal hernia after Miles operation (P < 0.05).

Conclusion

Advanced age, thickness of subcutaneous abdominal fat, BMI > 25 kg/m2, and transperitoneal surgical approach are independent risk factors for the formation of parastomal hernia after Miles.

Efficacy of laparoscopic surgery for loop colostomy: a propensity-score-matched analysis

PURPOSE

Colostomy is a common procedure for fecal diversion, but the optimal colostomy approach is unclear in terms of surgical outcomes and stoma-related complications. The purpose of this study was to examine the efficacy and feasibility of laparoscopic loop colostomy.

METHODS

This retrospective cohort study included patients who underwent loop colostomy at Shizuoka Cancer Center in Japan between April 2010 and March 2022. Patients were divided into two groups based on surgical approach: the laparoscopic (LAP) and open (OPEN) groups. Surgical outcomes and the incidences of stoma-related complications such as stomal prolapse (SP), parastomal hernia (PSH), and skin disorders (SD) were compared with and without propensity score matching.

RESULTS

Of the 388 eligible patients, 180 (46%) were in the LAP group and 208 (54%) were in the OPEN group. The male-to-female ratio was 5.5:4.5 in the Lap group and was 5.3:4.7 in the OPEN group, respectively. The median age was 68 years (range, 31-88 years) in the LAP group and 65 years (range, 23-93 years) in the OPEN group, respectively. The LAP group, compared with the OPEN group, had a shorter operative time and lower incidences of surgical site infection (3.9% versus 16.3%, respectively; p < 0.01) and SD (11.7% versus 24.5%, respectively; p < 0.01). There was no significant difference between the LAP and OPEN groups in the incidence of SP (17.3% versus 17.3%, respectively) or PSH (8.9% versus 6.7%, respectively). After propensity score matching, the incidences of surgical site infection and SD were significantly lower in the LAP group than in the OPEN group, while there were no significant differences in the operative time or the incidences of SP and PSH.

CONCLUSION

Our results suggest that laparoscopic surgery could be beneficial and feasible in loop colostomy.

The same parastomal hernia repairs rate in the different approaches to colostomy

PURPOSE

This study aimed to compare the parastomal hernia repairs rate in the different approaches to colostomy and investigate the risk factors for parastomal hernia formation in patients with permanent colostomies.

METHODS

Consecutive rectal cancer patients who underwent abdominoperineal resection from June 2014 to July 2020 in West China Hospital were divided into two groups according to their surgical approach for permanent colostomies. The impact of different approaches to colostomy on parastomal hernia repairs was determined by comparing a group of patients receiving an extraperitoneal route to colostomy with a group receiving transperitoneal. Potential variables were evaluated first with univariate and then multivariate analyses to identify the risk factors for the formation of parastomal hernia.

RESULTS

Two hundred two subjects in the transperitoneal group and 103 in the extraperitoneal group attended the follow-up visit with a median follow-up period of 33 (25th-75th percentiles, 17-46) months. Clinically and radiologically detectable parastomal hernias were present in 76 of 202 (37.6%) and 14 of 103 (13.6%) subjects in the transperitoneal and extraperitoneal groups during the follow-up period (p＜0.01). Besides, 10 of 76 (13.1%) subjects in the transperitoneal group and 2 of 14 (14.3%) subjects in the extraperitoneal group underwent a parastomal hernia operation during the follow-up (p = 0.82). In addition, the transperitoneal approach of colostomy (p = 0.002), older age (p＜0.001), and higher body mass index (p = 0.013) were identified as independent risk factors for the occurrence of parastomal hernia.

CONCLUSIONS

Extraperitoneal colostomy decreased the detectable parastomal hernias but did not reduce the surgical repair rate of parastomal hernias.

A technique for laparoscopic extraperitoneal colostomy with an intact posterior sheath of rectus

Regardless of the advances in surgical techniques, parastomal hernia is still an inevitable complication for many patients with low rectal cancer undergoing abdominal perineal resection (APR). Extraperitoneal colostomy (EPC) seems to be a effective method to reduce the risk of parastomal hernia. We propose a new approach to simplify and standardize laparoscopic EPC to make this operation easy to perform. We used the technique of laparoscopic TEP groin hernia repair to produce an extraperitoneal tunnel, which can not only facilitate precise visualization of the extraperitoneal tunnel but also utilize the intact posterior rectus abdominis sheath as biologic materials to maintain soft-tissue augmentation, with a satisfactory result. With laparoscopy, we can create adequate space without insufficient dissection of the extraperitoneal tunnel while avoiding damage to the retrorectus sheath. At the time of writing, we had performed this method in four patients, without any complications. This technique is effective at preventing parastomal hernia without extra costs.

Laparoscopic extraperitoneal colostomy has a lower risk of parastomal hernia and bowel obstruction than transperitoneal colostomy

PURPOSE

Several studies indicate that an extraperitoneal colostomy can prevent the development of a parastomal hernia (PSH) as compared to a transperitoneal colostomy. However, the clinical value of laparoscopic extraperitoneal colostomy, and its influence on bowel obstruction and PSH remain unclear. The present study aimed to clarify the impact of laparoscopic extraperitoneal colostomy on the development of a PSH and bowel obstruction.

METHODS

This study included 327 consecutive patients who underwent laparoscopic abdominoperineal resection or Hartmann's procedure between January 2013 and December 2019 after fulfilling selection criteria. The incidence of a PSH (Clavien-Dindo classification ≥ grade I) and bowel obstruction (≥ grade IIIa) in the transperitoneal and extraperitoneal route groups were analyzed using univariate and multivariate analysis.

RESULTS

The patients were classified into transperitoneal (n = 222) and extraperitoneal (n = 105) route groups. The patient characteristics, except for body mass index and operative time, were comparable between the groups. A PSH and bowel obstruction occurred more frequently in the transperitoneal than in the extraperitoneal route group (17.1% vs. 1.9% and 15.3% vs. 6.7%, respectively; p < 0.01 and p = 0.03, respectively). The multivariate analysis showed that age ≥ 70 years, body mass index ≥ 22.4 kg/m², and a transperitoneal route were independent risk factors for the development of a PSH, and a transperitoneal route was an independent risk factor for bowel obstruction.

CONCLUSIONS

The transperitoneal route was identified as a risk factor for the development of both a PSH and bowel obstruction after laparoscopic abdominoperineal resection or Hartmann's procedure.

Abdominal Oblique Internal and External Muscles Gap Colostomy for Lower Incidence of Parastomal Hernia and Higher Quality of Life: A Retrospective Cohort Study

BACKGROUND

Parastomal hernia and fecal incontinence cause severe distress to the rectal cancer patients with stoma after abdominoperineal resection. We attempted a new colostomy technique through the gap between the abdominal oblique internal and external muscles to prevent parastomal hernia and improve quality of life.

METHODS

This cohort study retrospectively examined clinical data from a total of 114 consecutive rectal cancer patients who underwent laparoscopic abdominoperineal resection in our center from March 2016 to March 2018 after propensity score matching. Group A included 57 patients who underwent colostomy through the gap between the abdominal oblique internal and oblique external muscles, while group B included 57 patients who underwent extraperitoneal colostomy. Patients' quality of life was evaluated using Fecal Incontinence Quality of Life (FIQL) Scale.

RESULTS

Group A had a lower incidence of parastomal hernia (0% vs. 15.7%, p = 0.004) and higher quality of life, especially in lifestyle, coping/behavior and embarrassment domains (all p values < 0.05) than group B both during the follow-up period. The incidence of other outcomes did not differ between the groups.

CONCLUSIONS

Colostomy through the gap between the abdominal oblique internal and oblique external muscle is a new technique showing both safety and effectiveness for preventing parastomal hernia and improving quality of life after laparoscopic abdominoperineal resection.

Extraperitoneal colostomy in robotic surgery for rectal cancer using a tip-up fenestrated grasper

INTRODUCTION

Although extraperitoneal colostomy could reduce the risk for parastomal hernia formation, it is often technically demanding to dissect the extraperitoneal route laparoscopically. Here, we demonstrate our original surgical technique for extraperitoneal tunneling using a robotic instrument.

MATERIALS AND SURGICAL TECHNIQUE

After total mesorectal excision (TME) and before specimen retrieval, the edge of the outer leaf of the parietal peritoneum was elevated by the grasper in the left hand and the tip-up fenestrated grasper (Tip-Up) in the right hand. The extraperitoneal tissue was opened using the scissor forceps (right hand). Then, extraperitoneal tunneling (inner tunnel) was performed using a Tip-Up with a width of approximately 4 cm that could reach adjacent to the lateral border of the abdominal rectus muscle. A round incision was made at a preoperatively marked site on the skin. The anterior rectal sheath was cut in a cruciate fashion. The abdominal rectus muscle was split, and then the posterior rectus sheath was cut longitudinally not just below the stoma marking site but also at a slant on the lateral side. The peritoneum was dissected with care to avoid opening the peritoneum. The outer side of the tunnel was broken through to the inner tunnel using an easy blunt dissection with two fingers. Kelly forceps were introduced through the extraperitoneal tunnel along with the fingers, and the stump of the sigmoid colon was grasped and exteriorized through this tunnel.

DISCUSSION

Robotic retroperitoneal tunneling using a Tip-Up is easy and useful for preventing parastomal hernia.

Modified technique of extraperitoneal colostomy without incision of the posterior rectus sheath

Extraperitoneal colostomy is a widely used technique during abdominoperineal resection (APR) operation for lower rectal cancer. This technique has been reported to be effective to prevent the postoperative parastomal hernia in some retrospective studies, however, there is still a certain incidence of parastomal hernia. A modification of the extraperitoneal colostomy technique is described in this paper that keeps posterior rectal sheath intact instead of having a conventional incision, to further reduce the risk of parastomal hernia. Until now, this modified technique has been performed in 15 patients, no occurrence of parastomal hernia was observed.

Comparison of different modalities for the diagnosis of parastomal hernia: a systematic review

PURPOSE

Parastomal hernia (PSH) is a common complication following stoma formation. The incidence of PSH varies widely due to several factors including differences in diagnostic modality, observer, definition, and classification used for diagnosing PSH. The aim of this systematic review was to evaluate the diagnostic accuracy of the modalities used to identify PSH.

METHODS

Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar databases were searched. Studies reporting PSH incidence rates detected by two or more different diagnostic modalities or inter-observer variation on one diagnostic modality were included. Article selection and assessment of study quality were conducted independently by two researchers using Cochrane Collaboration's tool for assessing risk of bias. PROSPERO registration: CRD42018112732.

RESULTS

Twenty-nine studies (n = 2514 patients) were included. Nineteen studies compared CT to clinical examination with relative difference in incidence rates ranging from 0.64 to 3.0 (n = 1369). Overall, 79% of studies found an increase in incidence rate when using CT. Disagreement between CT and clinical examination ranged between 0 and 37.3% with pooled inter-modality agreement Kappa value of 0.64 (95% CI 0.52-0.77). Four studies investigated the diagnostic accuracy of ultrasonography (n = 103). Compared with peroperative diagnosis, CT and ultrasonography both seemed accurate imaging modalities with a sensitivity of 83%.

CONCLUSION

CT is an accurate diagnostic modality for PSH diagnosis and increases PSH detection rates, as compared with clinical examination. Studies that specially focus on the diagnostic accuracy are needed and should aim to take patient-reported outcomes into account. A detailed description of the diagnostic approach, modality, definition, and involved observers is prerequisite for future PSH research.

Laparoscopic extraperitoneal sigmoid colostomy using the totally extraperitoneal hernia repair technique after abdominoperineal resection for rectal cancer

Stoma creation through the extraperitoneal route reportedly reduces the risk of parastomal hernia and stomal prolapse after abdominoperineal resection (APR) for rectal cancer. We describe a new technique for laparoscopic extraperitoneal sigmoid colostomy following APR. After the rectus abdominis muscle is separated, Lap ProtectorTM and EZ AccessTM devices are placed. An extraperitoneal stoma tunnel is created laparoscopically as much as possible. Next, the peritoneum is separated from the inside of the abdominal cavity, and the extraperitoneal tunnel is opened. At the time of writing, we had performed laparoscopic extraperitoneal sigmoid colostomy in eight patients, without any complications or conversion to the conventional procedure. Thus, laparoscopic extraperitoneal sigmoid colostomy is a useful and safe technique for the laparoscopic creation of an extraperitoneal stoma tunnel after APR.