Laparoscopic parastomal hernia repair

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.

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.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01509-y.

[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.

Robotic parastomal hernia repair

Introduction and Objective:

Annually, more than one hundred thousand new stomas are created in the United States and near 30-50% of those will develop parastomal hernia ( 1 ). Occasionally parastomal hernias may result in life threatening complications such as bowel obstruction or strangulation requiring urgent surgical intervention ( 2 ). The minimally invasive surgery for these hernias are preferred, specially when the primary case was either laparoscopic or robot-assisted. Our objective is to demonstrate a step-by-step robotic approach with and without mesh placement and their outcomes in two different scenarios: elective and emergency.

Materials and Methods:

We present two cases, a 56-year-old male with three years prior robot-assisted radical cystectomy with ileal conduit and a 82-year-old male with five year post operation of laparoscopic radical cystectomy with bilateral ureterostomies. Both of them had parastomal hernia, the first case was an urgency due to bowel obstruction while the second case was an elective procedure. Using three portals, we choose the primary repair for the first case and placement of a biological mesh within the keyhole technique ( 3 ) for the second one.

Results:

In the first case we had an operative time of 110min, total blood loss of 40cc and for the second case an operative time of 140min with total blood loss of 20cc. Both patients were discharged within 24h and had a follow-up of 2 years with no recurrence.

Conclusions:

The capability for complex sutures and dissection of intracorporeal structures makes the robotic platform a powerful ally ( 4 ) and we believe in its superiority over conventional laparoscopy. Although further studies are required, our initial series suggests that the robotic parastomal hernia repair is feasible and reproducible, with or without mesh placement and could be demonstrated its use for either elective or emergency situations.

Improved tissue integration of a new elastic intraperitoneal stoma mesh prosthesis

Parastomal herniation is a frequent complication in colorectal surgery, occurring with a prevalence of 30-80%. The aim of the study was to create a new intraperitoneal colostoma mesh prosthesis (IPST) with enhanced elastic properties made with thermoplastic polyurethane (TPU) monofilaments. We performed open terminal sigmoid colostomies reinforced with either a 10 cm by 10 cm polyvinylidene fluoride (PVDF) or a new TPU/PVDF composite mesh in a total of 10 minipigs. Colostoma was placed paramedian in the left lower abdomen and IPST meshes were fixed intraperitoneal. After 8 weeks, the animals were euthanized after laparoscopic exploration and specimen were explanted for histological investigations. Implantation of a new IPST-mesh with enhanced elastic properties was feasible in a minipig model within an observation period of 8 weeks. Immunohistochemically, Collagen I/III ratio as a marker of tissue integration was significantly higher in TPU-group versus PVDF group (9.4 ± 0.5 vs. 8.1 ± 0.5, p = 0.002) with a significantly lower inflammatory reaction measured by a smaller inner granuloma at mesh-colon interface (17.6 ± 3.3 μm vs. 23 ± 5 μm, p < 0.001). A new TPU/PVDF composite mesh with enhanced elastic properties as IPST was created. Stoma surgery and especially the evaluation of the new stoma mesh prosthesis are feasible with reproducible results in an animal model. Tissue integration expressed by Collagen I/III ratio seems to be improved in comparison to standard-elastic PVDF-IPST meshes.

Laparoscopic Modified Keyhole Technique with Coated Polyester Mesh for Treatment of Parastomal Hernia: Measures for Improving the Outcome

Purpose: Although the modified Sugarbaker technique gives good results for the treatment of parastomal hernia (PH), there are other valid options for the treatment of this frequent complication. In our practice, the laparoscopic keyhole (KH) technique, with some specific modifications, can give similar results. Materials and Methods: We collected data on all the patients with symptomatic PHs who underwent surgical repair between January 2002 and December 2017 in our surgical department. The primary endpoint was to evaluate the recurrence rate after at least 1 year, determined on the basis of physical examination during follow-up and on postprocedure radiological results. Results: Ninety patients were treated with the KH technique. The stomas that were treated were 83 end colostomies and 7 ileal ureterostomies. Eighty-eight patients were treated with polyester mesh (Parietex™, Medtronic, Ireland) and 2 with a composite mesh (Physiomesh™, Ethicon). Patients had median follow-up period of 1 year. Seroma occurred in 4 patients, who were treated conservatively by clinical monitoring. Four patients had a recurrence: 1 occurred on the seventh postoperative day, due to a technical error; 1 after 6 months, due to the partial shrinkage of the mesh into the defect; the third after 1 year, but it occurred at the beginning of our experience, and the last recurrence was after 3 years in a patient who gained 15 kg after the procedure. Conclusions: If a few precautionary steps are added to the original technique, laparoscopic KH repair is feasible and safe, giving good results in terms of complications and recurrence rates.

Prosthetic mesh placement for the prevention of parastomal herniation

BACKGROUND

Parastomal herniation is a common problem following formation of a stoma after both elective and emergency abdominal surgery. Symptomatic hernias give rise to a significant amount of patient morbidity, and in some cases mortality, and therefore may necessitate surgical treatment to repair the hernial defect and/or re-site the stoma. In an effort to reduce this complication, recent research has focused on the application of a synthetic or biological mesh, inserted during stoma formation to help strengthen the abdominal wall.

OBJECTIVES

The primary objective was to evaluate whether mesh reinforcement during stoma formation reduces the incidence of parastomal herniation. Secondary objectives included the safety or potential harms or both of mesh placement in terms of stoma-related infections, mesh-related infections, patient-reported symptoms/postoperative quality of life, and re-hospitalisation/ambulatory visits.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2018, Issue 1), Ovid MEDLINE (1970 to 11 January 2018), Ovid Embase (1974 to 11 January 2018), and Science Citation Index Expanded (1970 to 11 January 2018). To identify ongoing studies, we also searched the metaRegister of Controlled Trials (mRCT) on 11 January 2018.

SELECTION CRITERIA

We considered for inclusion all randomised controlled trials (RCTs) of prosthetic mesh (including biological/composite mesh) placement versus a control group (no mesh) for the prevention of parastomal hernia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies identified by the literature search for potential eligibility. We obtained the full articles for all studies that potentially met the inclusion criteria and included all those that met the criteria. Any differences in opinion between review authors were resolved by consensus. We pooled study data into a meta-analysis. We assessed heterogeneity by calculation of I² and expressed results for each variable as a risk ratio (RR) with corresponding 95% confidence intervals (CI). We expressed continous outcomes as mean difference (MD) with corresponding 95% CIs.

MAIN RESULTS

We included 10 RCTs involving a total of 844 participants. The primary outcome was overall incidence of parastomal herniation. Secondary outcomes were rate of reoperation at 12 months, operative time, postoperative length of hospital stay, stoma-related infections, mesh-related infections, quality of life, and rehospitalisation rate. We judged the risk of bias across all domains to be low in six trials. We judged four trials to have an overall high risk of bias.The overall incidence of parastomal hernia was less in participants receiving a prophylactic mesh compared to those who had a standard ostomy formation (RR 0.53, 95% CI 0.43 to 0.66; 10 studies, 771 participants; I² = 69%; low-quality evidence). In absolute numbers, the incidence of parastomal hernia was 22 per 100 participants (18 to 27) receiving prophylactic mesh compared to 41 per 100 participants having a standard ostomy formation.There were no differences in the need for reoperation (RR 0.90, 95% CI 0.50 to 1.64; 9 studies, 757 participants; I² = 0%; low-quality evidence); operative time (MD -6.50 (min), 95% CI -18.24 to 5.24; 6 studies, 671 participants; low-quality evidence); postoperative length of hospital stay (MD -0.95 (days), 95% CI -2.03 to 0.70; 4 studies, 500 participants; moderate-quality evidence); or stoma-related infections (RR 0.89, 95% CI 0.32 to 2.50; 6 studies, 472 participants; I² = 0%; low-quality evidence) between the two groups.We were unable to analyse mesh-related infections, quality of life, and rehospitalisation rate due to sparse data or because the outcome was not reported in the included studies.

AUTHORS' CONCLUSIONS

This Cochrane Review included 10 RCTs with a total of 844 participants. The review demonstrated a reduction in the incidence of parastomal hernia in people who had a prophylactic synthetic mesh placed at the time of the index operation compared to a standard ostomy formation. However, our confidence in this estimate is low due to the presence of a large degree of clinical heterogeneity, as well as high variability in follow-up duration and technique of parastomal herniation detection. We found the rate of stoma-related infection to be similar in both the intervention and control groups.

Synthetic vs biologic mesh for the repair and prevention of parastomal hernia

AIM

To outline current evidence regarding prevention and treatment of parastomal hernia and to compare use of synthetic and biologic mesh.

METHODS

Relevant databases were searched for studies reporting hernia recurrence, wound and mesh infection, other complications, surgical techniques and mortality. Weighted pooled proportions (95%CI) were calculated using StatsDirect. Heterogeneity concerning outcome measures was determined using Cochran’s Q test and was quantified using I². Random and fixed effects models were used. Meta-analysis was performed with Review Manager software with the statistical significance set at P ≤ 0.05.

RESULTS

Forty-four studies were included: 5 reporting biologic mesh repairs; 21, synthetic mesh repairs; and 18, prophylactic mesh repairs. Most of the studies were retrospective cohorts of low to moderate quality. The hernia recurrence rate was higher after undergoing biologic compared to synthetic mesh repair (24.0% vs 15.1%, P = 0.01). No significant difference was found concerning wound and mesh infection (5.6% vs 2.8%; 0% vs 3.1%). Open and laparoscopic techniques were comparable regarding recurrences and infections. Prophylactic mesh placement reduced the occurrence of a parastomal hernia (OR = 0.20, P < 0.0006) without increasing wound infection [7.8% vs 8.2% (OR = 1.04, P = 0.91)] and without differences between the mesh types.

CONCLUSION

There is no superiority of biologic over synthetic mesh for parastomal hernia repair. Prophylactic mesh placement during the initial surgery significantly reduces parastomal hernia occurrence regardless of the mesh type.

Symptom load and individual symptoms before and after repair of parastomal hernia: a prospective single centre study

AIM

The symptom load and individual symptoms before and after repair of parastomal hernia were investigated.

METHOD

Stoma-related symptoms were prospectively recorded before repair of a parastomal hernia and at 10 days and 6 months postoperatively: leakage, skin problems, difficulty with the appliance, limitation of activity, difficulty with clothing, cosmetic complaints, social restriction, erratic action of the stoma, a bearing-down sensation at the site of the stoma and pain. Episodes of intermittent bowel obstruction and difficulty with irrigation were also recorded. Patients were seen at 1, 2 and 3 years and were examined for recurrent parastomal herniation.

RESULTS

Of 131 consecutive patients referred to a specialized centre for treatment of parastomal bulging, 61 underwent parastomal hernia repair. Forty-eight patients were treated with the Sugarbaker technique. Six different symptoms were present in more than half the patients before surgery. The overall symptom load decreased significantly from a median of 4 [interquartile range (IQR) 2.5-6] preoperatively to 2 (IQR 1-3) on postoperative day 10 and 1 (IQR 0-2) at 6 months, P < 0.001. The number of symptoms decreased in 93% of patients; in 5% there was no change and in 2% symptoms increased. Skin problems and leakage were the only symptoms that were not significantly reduced. The overall recurrence rate of herniation was 5/48 (10%) at a median of 12 (IQR 6-24) months.

CONCLUSION

The preoperative symptom load was high and this fell after repair in over 90% of patients. Recurrence occurred in 10% of patients within 2 years of repair. The study emphasizes the importance of detailed knowledge of the symptoms of parastomal hernia when addressing and managing patients' problems and complaints.

Modified laparoscopic Sugarbaker repair decreases recurrence rates of parastomal hernia

BACKGROUND

Parastomal hernia (PH) is a frequent complication of stoma formation, and recurrence after repair is common. A laparoscopic modified Sugarbaker technique (SB) may decrease the recurrence of PH compared with other methods.

METHODS

A retrospective review, approved by the institutional review board, of patients who underwent PH repair between 2004 and 2014 was performed. Demographics, factors for ostomy formation, hernia risk factors, intraoperative and postoperative information, and recurrence data were compared among SB and other techniques. Time to recurrence was compared between SB versus other techniques with the Kaplan-Meier method and adjusted Cox proportional hazards regression modeling.

RESULTS

Sixty-two PH repairs were performed: 39 (61%) paraileostomy and 23 (39%) paracolostomy. Repairs included 25 laparoscopic modified SB and 37 from other techniques. There was no difference in demographics. Postoperative complication rate was lesser in SB versus all other groups (40% vs 76%, P = .02). Recurrence rates were lesser for SB versus all others (16% vs 60%, P < .001). Follow-up was similar among all groups. After adjustment, SB was found to be protective of recurrences (hazard ratio = .28, 95% confidence interval = 0.09-0.82).

CONCLUSION

A laparoscopic modified SB technique provides decreased rates of recurrence and postoperative complications compared with other approaches.

Repair of complex parastomal hernias

Development of parastomal hernias (PH) is very common after stoma formation and carries a risk of subsequent bowel incarceration, obstruction and strangulation. The management of PH remains a challenge for the colorectal surgeon, and there are currently no standardized guidelines for the treatment of PH. Even more difficult is the management of complex parastomal hernias (CPH). We conducted a review of the literature to identify recent developments in the treatment of CPH, including analysis of the use of synthetic and biologic mesh prostheses, method of mesh placement and surgical approach.

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.

Single-port laparoscopic parastomal hernia repair with modified sugarbaker technique

Single-port laparoscopic parastomal hernia repair with a modified Sugarbaker technique is suggested to be feasible and safe and provides an alternative to multi-port surgery.

Introduction:

Laparoscopic parastomal hernia repair with modified Sugarbaker technique has become increasingly the operation of choice because of its low recurrence rates. This study aimed to assess feasibility, safety, and efficiency of performing the same operation with single-incision laparoscopic surgery.

Materials and Methods:

All patients referred from March 2010 to February 2013 were considered for single-port laparoscopic repair with modified Sugarbaker technique. A SILS port (Covidien, Norwalk, Connecticut, USA) was used together with conventional straight dissecting instruments and a 5.5- mm/52-cm/30° laparoscope. Important technical aspects include modified dissection techniques, namely, “inline” and “chopsticks” to overcome loss of triangulation, insertion of a urinary catheter into an ostomy for ostomy limb identification, safe adhesiolysis by avoiding electocautery, saline -jet dissection to demarcate tissue planes, dissection of an entire laparotomy scar to expose incidental incisional hernias, adequate mobilization of an ostomy limb for lateralization, and wide overlapping of defect with antiadhesive mesh.

Results:

Of 6 patients, 5 underwent single-port laparoscopic repair, and 1 (whose body mass index [BMI] of 39.4 kg/m² did not permit SILS port placement) underwent multiport repair. Mean defect size was 10 cm, and mean mesh size was 660 cm² with 4 patients having incidental incisional hernias repaired by the same mesh. Mean operation time was 270 minutes, and mean hospital stay was 4 days. Appliance malfunction ceased immediately, and pain associated with parastomal hernia disappeared. There was no recurrence with a follow-up of 2 to 36 months.

Conclusion:

Compared with multiport repair, single-port laparoscopic parastomal repair with modified Sugarbaker technique is safe and efficient, and it may eventually become the standard of care.

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.

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.

Laparoscopic versus open repair of parastomal hernias: an ACS-NSQIP analysis of short-term outcomes

BACKGROUND

Parastomal hernia (PSH) is a frequent complication following the creation of a stoma. While a significant number of cases require operative management, data comparing short-term outcomes of laparoscopic versus open repair of parastomal hernias are limited.

METHODS

The ACS-NSQIP was retrospectively reviewed from 2005 to 2011 for all PSH cases that underwent open or laparoscopic repair. Patients characteristics, operative details, and outcomes were listed for both procedure types. Selected end points were compared on multivariate regression analysis.

RESULTS

Among the 2,167 identified parastomal hernia cases, only 222 (10.24 %) were treated laparoscopically. The open and laparoscopic groups were similar with respect to mean patient age (63 vs. 63 years; p = 1) and gender distribution as the majority of patients were females (56.8 %). However, open repair was more likely to be performed in patients with a higher ASA class (III and IV) (p < 0.001). Also, the open approach was more likely to be used emergently (8.64 vs. 3.60 %; p = 0.01) and for recurrent hernias (6.99 vs. 3.15 %; p < 0.05). After adjusting for all potential confounders including age, gender, ASA, emergency designation of the operation, hernia type, and wound class, laparoscopy was associated with shorter operative time (137.5 vs. 153.4 min; p < 0.05), shorter length of hospital stay by 3.32 days (p < 0.001), lower risk of overall morbidity (OR = 0.42; p < 0.001), and a lower risk of surgical site infections (OR = 0.35; p < 0.01) compared to open repair. Mortality rates were similar in the laparoscopic and open groups (0.45 vs. 1.59 %, respectively; p = 0.29).

CONCLUSIONS

Laparoscopic parastomal hernia repair is safe and appears to be associated with better short-term outcomes compared to open repair in selected cases. Large prospective randomized trials are needed to confirm those results and to assess long-term recurrence rates.

Laparoscopic fascial suture repair of parastomal hernia

Parastomal hernia is a recognised complication following stoma formation, representing a challenging problem to surgeons. At least three approaches for parastomal hernia repair have been described: fascial suture repair, relocation of stoma and local repair with use of mesh. In simple fascial suture repair only open techniques have been described. Relocation of stoma can be complicated with another parastomal hernia at the new site and risk of incisional hernia at the site of previous stoma. Mesh repair can be either open or laparoscopic. The recurrence rate and complications of parastomal hernia repair remain very high. We have invented a simple fascial suture laparoscopic repair of parastomal hernia with the use of the Crochet hook needle (EndoClose). This new technique may result in reduced pain, earlier discharge from hospital and reduced risk of infection as there is no mesh used as well as reduced risk of seroma 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.

The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study

BACKGROUND

Parastomal hernia is a frequent complication of intestinal stomata. Mesh repair gives the best results, with the mesh inserted via laparotomy or laparoscopically. It was the aim of this retrospective multicenter study to determine the early and late results of the laparoscopically performed, modified Sugarbaker technique with ePTFE mesh.

METHODS

From 2005 to 2010, a total of 61 consecutive patients (mean age = 61 years), with a symptomatic parastomal hernia, underwent laparoscopic repair using the modified Sugarbaker technique with ePTFE mesh. Fifty-five patients had a colostomy, 4 patients an ileostomy, and 2 a urostomy according to Bricker. The records of the patients were reviewed with respect to patient characteristics, postoperative morbidity, and mortality. All patients underwent physical examination after a follow-up of at least 1 year to detect a recurrent hernia. Morbidity rate was 19 % and included wound infection (n = 1), ileus (n = 2), trocar site bleeding (n = 2), reintervention (n = 2), and pneumonia (n = 1). One patient died in the postoperative period due to metastasis of lung carcinoma that caused bowel obstruction. Concomitant incisional hernias were detected in 25 of 61 patients (41 %) and could be repaired at the same time in all cases. A recurrent hernia was found in three patients at physical examination, and in one patient an asymptomatic recurrence was found on a CT scan. The overall recurrence rate was 6.6 % after a mean follow-up of 26 months.

CONCLUSION

The laparoscopic Sugarbaker technique is a safe procedure for repairing parastomal hernias. In our study, the overall morbidity was 19 % and the recurrence rate was 6.6 % after a mean follow-up of 26 months. Moreover, the laparoscopic approach revealed concomitant hernias in 41 % of the patients, which could be repaired successfully at the same time.

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.

[Correction of parastomal hernia using meshes]

The incidence of parastomal hernia in ileal conduit urinary diversion ranges from 4% to 16%. Surgical correction is necessary in about one third of cases and different techniques of surgical reconstruction have been described. Primary fascial repair has a high recurrence rate of 46-100% whereas stoma translocation is associated with complication rates of up to 88%. The use of alloplastic material (usually polypropylene meshes) has reduced the recurrence rate by up to 100% for primary fascial repair and 71% for stoma translocation down to 33%.Composite meshes consist of two layers, a polypropylene layer and an expanded polytetrafluoroethylene (ePTFE) layer. The former is placed against the abdominal wall for permanent reinforcement by ingrowing connective tissue and the ePTFE layer is placed against the abdominal organs preventing adhesions with the bowel. The intraperitoneal placement of such composite meshes is a standardized, simplified, gentle and controllable surgical procedure. This article reports experiences with the surgical correction of parastomal hernias in ileal conduits using composite meshes.

Laparoscopic repair of incisional and other complex abdominal wall hernias

Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy. The high incidence of hernia formation significantly contributes to both patient morbidity and health care costs. Although a variety of approaches have been described to repair these defects, historically the results have been disappointing. Recurrence rates after primary repair have been reported to range from 24% to 54%. The recent advent of laparoscopic ventral hernia repair (LVHR) has offered promising outcomes by combining tension-free repair using a prosthesis with minimally invasive techniques, lowering reported recurrence rates to <10%. This review discusses standardized, well-researched techniques that have contributed to the success of LVHR. We also discuss how these techniques have been modified for laparoscopic repair of suprapubic lumbar hernias, hernias near the iliac crest, and parastomal hernias. In addition, we review our own experience with LVHR in the context of the principles discussed.

Systematic review of the use of a mesh to prevent parastomal hernia

BACKGROUND

Parastomal hernia is a major complication after stoma placement. Surgical procedures for repairing parastomal hernia are difficult and their failure rate is high. The use of a mesh implanted at the primary operation has shown promising results. Therefore, we performed a systematic review of the literature to evaluate the results of the placement of mesh at the time of stoma formation with the aim of preventing parastomal hernia.

METHODS

The Medline, Embase, and Cochrane Library databases were searched using the keywords "parastomal or paracolostomy hernia." Data regarding the incidence of hernia, the operative parameters, including mesh placement and types, and complications, including infection, stoma necrosis, and stenosis, were used and analyzed to evaluate the use of prophylactic mesh at the time of stoma formation.

RESULTS

Three randomized controlled trials, three prospective observational series, and one retrospective study were selected and summarized. During the follow-up period (observation time of 1-83 months), parastomal hernia was present in 32/58 patients (55%) who did not have mesh placement and in 14/179 patients (7.82%) in whom mesh was used. Meta-analysis of three randomized controlled trials showed that prophylactic use of the mesh significantly diminished the incidence of parastomal hernia (p < 0.0001). Postoperative morbidity levels were similar whether the mesh was placed or not.

CONCLUSION

Prophylactic use of mesh at the time of stoma formation is a safe procedure and reduces the risk of parastomal hernia. For more detailed evaluation, additional large, double-blinded, randomized controlled trials with long-term follow-up are necessary.

[Laparoscopic repair of parastomal hernia]

Parastomal hernias are a common complication after stoma formation. An exact evaluation of the history of the patients reveals clinically impairing symptoms in the majority of patients. The surgical treatment should generally be based on the augmentation or even replacement of the abdominal wall by non-resorbable meshes. The laparoscopic repair can be performed using the intraperitoneal placement of a mesh according to Sugarbaker with a wide lateralization of the stoma loop, the keyhole-technique, which means an incised mesh placed around the stoma loop, or the combination of both techniques (sandwich-technique). By far the best results can be achieved with the sandwich-technique. The recurrence rate in our series is less than 3% with an acceptable complication rate. The literature demonstrates high recurrence rates after keyhole-repair and the Sugarbaker-technique was also shown to be ineffective by our own data. In summary the laparoscopic sandwich-technique is a technically challenging but very successful method for long-lasting repair of parastomal hernias leading to an astonishingly low recurrence rate.

Repair of parastomal hernias with biologic grafts: a systematic review

BACKGROUND

Biologic grafts are increasingly used instead of synthetic mesh for parastomal hernia repair due to concerns of synthetic mesh-related complications. This systematic review was designed to evaluate the use of these collagen-based scaffolds for the repair of parastomal hernias.

METHODS

Studies were retrieved after searching the electronic databases MEDLINE, EMBASE and Cochrane CENTRAL. The search terms 'paracolostomy', 'paraileostomy', 'parastomal', 'colostomy', 'ileostomy', 'hernia', 'defect', 'closure', 'repair' and 'reconstruction' were used. Selection of studies and assessment of methodological quality were performed with a modified MINORS index. All reports on repair of parastomal hernias using a collagen-based biologic scaffold to reinforce or bridge the defect were included. Outcomes were recurrence rate, mortality and morbidity.

RESULTS

Four retrospective studies with a combined enrolment of 57 patients were included. Recurrence occurred in 15.7% (95% confidence interval [CI] 7.8-25.9) of patients and wound-related complications in 26.2% (95% CI 14.7-39.5). No mortality or graft infections were reported.

CONCLUSIONS

The use of reinforcing or bridging biologic grafts during parastomal hernia repair results in acceptable rates of recurrence and complications. However, given the similar rates of recurrence and complications achieved using synthetic mesh in this scenario, the evidence does not support use of biologic grafts.

First experience for the laparoscopic treatment of parastomal hernia with the use of Parietex composite mesh

Parastomal herniation is a postoperative complication after colostomy or ileostomy with an incidence rate of 0-48.1%. Its repair is indicated in approximately 10-15% of cases; however, this surgery has been associated with a significant degree of morbidity and recurrence. We describe, for the first time in literature, an experience using a new technique, and a new type of mesh. This new type of laparoscopic parastomal hernia repair appears to be easier and faster. The follow-up was about 240 days. Our preliminary experience in using this technique and mesh appears to be possibly leading to a reduction of recurrences and complications. Randomized multicenter studies are required to assess the true effectiveness of the technique.

Long-term follow-up of laparoscopic repair of parastomal hernia using a bilayer mesh with a slit

BACKGROUND

Open surgery for parastomal hernia has been associated with high morbidity and recurrence rates exceeding 50%. Laparoscopic mesh repair is a promising alternative. Published series on laparoscopic mesh repair of parastomal hernia, however, are few with relative short follow-up.

METHODS

Seventy-two consecutive patients with 48 paracolostomy and 24 paraileostomy hernias were studied prospectively. Using a two-layer mesh with polypropylene on the parietal side and nonadhesive PTFE toward the viscera, a slit with a central keyhole was cut in the mesh modified after Hofstetter. Covering the fascial defect, the slit was closed laterally. Of the 70 patients discharged alive, 66 were followed for 6 months to 11 years (median=3 years). Four patients were lost for follow-up.

RESULTS

Lysis of adhesions to the anterior abdominal wall, necessary in 68 patients (94%), was frequently a cumbersome and time-consuming task. In nine patients it was the apparent cause of inadvertent full-thickness enterotomy and seromuscular lesion in three and six patients, respectively. Three procedures (4%) were converted to open surgery. Postoperative complications were observed in 16 patients (22%), nine of whom required repeat surgery (13%). Two patients (3%) died. The median hospital stay was 3 days. Late mesh-related complications were observed in five patients (7%) after 5-34 months. Three patients developed abscess that required mesh removal in two patients, including one patient with a small bowel fistula. In two patients the mesh was removed because of small-bowel obstruction and stenosis of the colon at the level of the mesh, respectively. Parastomal hernia recurred in two patients 1 month and 52 months after surgery (recurrence rate=3%, 95% confidence interval=1-10).

CONCLUSIONS

Laparoscopic repair of parastomal hernia using bilayer mesh with a slit is associated with a risk of substantial postoperative morbidity, including late mesh-related complications, but a recurrence rate of less than 10%.

Surgery of recurrent parastomal hernia: direct repair or relocation?

PURPOSE

Parastomal hernia is a common late complication after stoma creation. The management options are many; unfortunately, most literature suggests unsatisfactory results. There are few studies comparing the outcomes after repair of parastomal hernias especially in recurrent cases, and the results are controversial. The aim of this study was to compare outcomes after repair of recurrent parastomal hernias between direct repair (DR) and relocation (RL).

METHOD

We performed a retrospective chart review of patients who underwent direct repair or RL for recurrent parastomal hernia during the period between 1990 and 2005. Perioperative data and re-recurrence rates were obtained and analysed with appropriate statistical methods.

RESULTS

With mean follow-up time of 2 years, 50 operations were available for evaluation; 27 (54%) DR and 23 (46%) RL [five same-side RL (SSRL) and 18 opposite-side RL (OSRL)]. There were no deaths and there were similar complication rates between groups. Four of five (80%) SSRL had a re-recurrent parastomal hernia. Considering only DR with OSRL, although OSRL had longer operative time and hospital stay than DR, the re-recurrence rate was lower (38%vs 74%; P = 0.02). However, with Kaplan-Meier calculated and longer predicted follow-up time, re-recurrence rates were similar (Log rank P = 0.09).

CONCLUSION

Recurrent parastomal hernia repair is associated with high re-recurrence rates.OSRL seems to have promising short-term outcomes; however, whether these results hold up long-term remains unclear. Therefore, larger cohorts of patients with longer follow-up or prospective randomized trials are needed.

Parastomal hernia repair: laparoscopic ventral hernia meshplasty with stoma relocation. The current state and a clinical case presentation

BACKGROUND

Parastomal hernia is a frequent complication after performing an ostomy, and although different technical options have been described, it lacks an ideal intervention to resolve it. The use of meshes and the laparoscopic approach, has led to a significant advance in resolving this condition. However, the ideal technique should guarantee must ensure integral repair of the abdominal wall, taking into account the functionality of the stoma. In large parastomal eventrations the repairing of the ventral hernia with a mesh and relocating the stoma in another quadrant may be an intervention that fulfills both principles, and open approach being described.

METHODS

We review the current state of surgical management of this condition and analyze the different technical options. Present the first description for using a laparoscopic technique with meshplasty and stoma relocation in an obese patient with a complex parastomal hernia, with results in the 18 month follow up.

CONCLUSIONS

Surgical technique repair of the parastomal hernia is sometimes a complex issue, which possibly requires different solutions according to the characteristics of the hernia and patient. The technique described of meshplasty with stoma relocation by laparoscopic approach has been revealed as an affordable technique, with minor inconvenience to the patient, absence of complications and good functional results in the long term, benefiting from the advantages of minimally invasive surgery itself.

Prevention of parastomal hernia by the placement of a mesh at the primary operation

INTRODUCTION

Parastomal hernia is a well known clinical problem, and up to 50% of all patients having a stoma will eventually develop a parastomal hernia. There are many surgical options available for the repair of a parastomal hernia, but the prevention of hernia development has only recently received scientific attention. The most encouraging results have included the use of a mesh inserted at the primary operation. We have, therefore, chosen to review the literature regarding the results of operative techniques, including mesh placement, for the prevention of a parastomal hernia.

MATERIALS

We performed a systematic literature search and found five publications which, in total, included 112 patients having a prophylactic mesh during their stoma formation. One study was a randomized controlled trial which included 54 patients, of which, 21 patients had a prophylactic mesh. The remaining four studies were prospective observational series.

RESULTS

Three of the 112 patients had a hernia recurrence within the follow-up period, which ranged from 2 to 48 months. One of the 52 patients that had a sublay mesh placed at the primary operation and two of 60 patients that had an onlay mesh developed a hernia. There were no infections or other serious complications related to the mesh in any of the studies.

CONCLUSION

The results of placing a prophylactic mesh when performing a permanent stoma in the elective situation are very promising. However, the data are preliminary and with relatively short follow-up times. Therefore, it should be confirmed in larger, double-blinded, controlled randomized clinical trials whether there are short- and long-term advantages of placing a mesh at the primary operation, and where the mesh should be placed in the abdominal wall.