Modified Pauli abdominal wall reconstruction for recurrent parastomal hernia after a Sugarbaker repair - a video vignette

High recurrence rate after posterior component separation and keyhole mesh reconstruction for complex parastomal hernia: A case series study

AIM

This study aimed to describe the results of complex parastomal hernia repair after posterior component separation and keyhole reconstruction.

METHOD

We conducted a retrospective review of a prospectively sustained database in one single complex abdominal wall referral centre. We analysed the data of patients who underwent the posterior component separation technique using modified transversus abdominis release for complex parastomal hernia and retromuscular keyhole mesh repair from February 2014 to January 2017. Demographic data, hernia characteristics, operative details and outcomes were analysed. The primary outcome measured was the recurrence rate during the follow-up.

RESULTS

Twenty patients were included in this study. Among the patients who underwent surgery for parastomal hernia, 17 patients had a colostomy (85%) and three patients had a ureteroileostomy after the Bricker procedure (15%). The mean body mass index was 33.2 kg/m² (range 25-47). Twelve patients had an expected associated risk according to the Carolinas equation for determining associated risk classification of >60%. Sixty per cent of our patients had contaminated or dirty/infected wounds. The overall complication rate was 60%. Surgical site infection was observed in 25% of the cases. The mortality rate in our study group was 5% (n = 1). We found clinical or radiological evidence of parastomal hernia recurrence in nine out of 20 (45%) patients during follow-up. No hernia recurrence was detected in the concomitant incisional hernias.

CONCLUSIONS

Although posterior component separation in the form of modified transversus abdominis muscle release allows abdominal wall reconstruction, keyhole mesh configuration at the stoma site does not offer satisfactory results in terms of long-term recurrence rate at the parastomal defect.

Second Look After Retromuscular Repair With the Combination of Absorbable and Permanent Meshes

Objective: The aim of this study is to describe the macroscopic features and histologic details observed after retromuscular abdominal wall reconstruction with the combination of an absorbable mesh and a permanent mesh.

Methods: We have considered all patients that underwent abdominal wall reconstruction (AWR) with the combination of two meshes that required to be reoperated for any reason. Data was extracted from a prospective multicenter study from 2012 to 2019. Macroscopic evaluation of parietal adhesions and histological analysis were carried out in this group of patients.

Results: Among 466 patients with AWR, we identified 26 patients that underwent a reoperation after abdominal wall reconstruction using absorbable and permanent mesh. In eight patients, the reoperation was related to abdominal wall issues: four patients were reoperated due to recurrence, three patients required an operation for chronic mesh infection and one patient for symptomatic bulging. A miscellanea of pathologies was the cause for reoperation in 18 patients. During the second surgical procedures made after a minimum of 3 months follow-up, a fibrous tissue between the permanent mesh covering and protecting the peritoneum was identified. This fibrous tissue facilitated blunt dissection between the permanent material and the peritoneum. Samples of this tissue were obtained for histological examination. No case of severe adhesions to the abdominal wall was seen. In four cases, the reoperation could be carried out laparoscopically with minimal adhesions from the previous procedure.

Conclusions: The reoperations performed after the combination of absorbable and permanent meshes have shown that the absorbable mesh acts as a protective barrier and is replaced by a fibrous layer rich in collagen. In the cases requiring new hernia repair, the layer between peritoneum and permanent mesh could be dissected without special difficulty. Few intraperitoneal adhesions to the abdominal wall were observed, mainly filmy, easy to detach, facilitating reoperations.