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Kritharides N, Papaconstantinou D, Kykalos S, Machairas N, Schizas D, Nikiteas NI, Dimitroulis D. Laparoscopic parastomal hernia repair: keyhole, Sugarbaker, sandwich, or hybrid technique with 3D mesh? An updated systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:448. [PMID: 38017096 PMCID: PMC10684625 DOI: 10.1007/s00423-023-03177-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023]
Abstract
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.
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Affiliation(s)
- Nicos Kritharides
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Ag. Thoma 17, 11527, Athens, Greece.
- Department of Surgery, General Hospital of Athens «Elpis», 11522, Athens, Greece.
| | - Dimitrios Papaconstantinou
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, 12462, Chaidari, Greece
| | - Stylianos Kykalos
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Ag. Thoma 17, 11527, Athens, Greece
| | - Nikolaos Machairas
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Ag. Thoma 17, 11527, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Nikolaos I Nikiteas
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Ag. Thoma 17, 11527, Athens, Greece
| | - Dimitrios Dimitroulis
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Ag. Thoma 17, 11527, Athens, Greece
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Sugarbaker Versus Keyhole Repair for Parastomal Hernia: a Systematic Review and Meta-analysis of Comparative Studies. J Gastrointest Surg 2022; 27:573-584. [PMID: 36469282 DOI: 10.1007/s11605-022-05412-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/03/2022] [Indexed: 01/20/2023]
Abstract
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.
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Stoma-Related Complications: A Single-Center Experience and Literature Review. JOURNAL OF INTERDISCIPLINARY MEDICINE 2022. [DOI: 10.2478/jim-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: The creation of an abdominal stoma is a common procedure performed by surgeons as a part of the treatment for benign and malignant conditions in general surgery. Stoma formation is simple, but sometimes the associated postoperative complications have an impact on the patients’ physical and psychological state. The majority of complications do not require reoperation, but when it is indicated, we have to assess the most appropriate option for the patient.
Material and Methods: We conducted a retrospective study in a single surgical center, the Department of Surgery, Mureș County Hospital, Târgu Mureș, Romania, using data from patients who have been admitted under elective conditions for stoma-related complications between 2005 and 2019.
Results: A total number of 877 ostomies (653 colostomies and 224 ileostomies) were performed, and 157 patients (17.9%) developed some type of stoma complication and required surgical intervention. The mean age was 64.5 ± 2.1 years, with a male-female ratio of 1.3 to 1. The leading comorbidities included cardiovascular disease (52.2% of cases), obesity (22.2%), and diabetes (18.4%). Parastomal hernia was the most frequent complication (47.5% of cases), followed by stoma prolapse (23.4%), parastomal stenosis (20.3%), and parastomal infection (8.2%). There was an association between age and the type of complication: parastomal hernia, stoma prolapse, and stenosis were more frequent in the elderly; parastomal infection was more prevalent in young patients. A longer hospital stay was observed in case of parastomal hernia.
Conclusions: Stoma formation is associated with significant morbidity. Typically, the complications appear in the elderly. Conservative treatment is essential, but some of the late complications, such as parastomal hernia, stoma stenosis, stoma prolapse, and parastomal infection, require a surgical solution. Parastomal hernias are the most common complications, frequently associated with comorbidities and prolonged hospitalization.
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From keyhole to sandwich: change in laparoscopic repair of parastomal hernias at a single centre. Surg Endosc 2020; 35:1863-1871. [PMID: 32342214 DOI: 10.1007/s00464-020-07589-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Nearly 50% of patients with an ostomy will develop a parastomal hernia (PSH). Its repair remains a surgical challenge. Both laparoscopic "modified Sugarbaker" (SB) and Keyhole (KH) repair are currently in use, frequently with unsatisfactory results.''Sandwich Repair'' (SR) may be an alternative to reduce recurrence rates. We present the change of our technique from KH to SR. METHODS We collected data from all consecutive laparoscopic PSH repairs at our institution from 2004 until now (from 2004 to 2013 treated with KH, from 2014 with SR) and compared the results of the two groups. Primary endpoint was recurrence rate at 1 year. Secondary outcomes were operative time, PO length of hospital stay (LOS), and short and long-term complications. RESULTS 13 patients underwent SR. Main changes in surgical technique concerned primary defect closure, no stay sutures, use of glue for first mesh fixation, and partial lateral covering of the underlying mesh with a peritoneal flap. Early postoperative course after SR was uneventful and no recurrence at 1 year was recorded. In the KH group (19 patients), short-term complications occurred in two cases (10%), with one parietal hematoma and one case of intensive pain; we had four recurrences at 1 year (21%). LOS was shorter in the SR group (mean 4 days vs 6, p = 0.004). The KH group had 2 (10%) occurrences of chronic seroma and one bowel perforation (5%), while the SR group had one (8%) occurrence of chronic pain. Median follow-up was 26 months (range 13-78) for the SR group and 47 months (12-105) for the KH group. CONCLUSION SR is safe and effective in expert hands and provides promising preliminary results.
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Olmi S, Oldani A, Uccelli M, Scotto B, Cesana G, Ciccarese F, Villa R, Giorgi R. Laparoscopic Modified Keyhole Technique with Coated Polyester Mesh for Treatment of Parastomal Hernia: Measures for Improving the Outcome. J Laparoendosc Adv Surg Tech A 2019; 29:681-684. [PMID: 30767697 DOI: 10.1089/lap.2018.0730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Stefano Olmi
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Alberto Oldani
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Matteo Uccelli
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Bruno Scotto
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Giovanni Cesana
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Francesca Ciccarese
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Roberta Villa
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
| | - Riccardo Giorgi
- General and Oncological Surgery Unit, Policlinico San Marco GSD, Osio Sotto, Italy
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Maciel V, Mata W, Arevalo G, Zeichen M, Glass T. Robotic retro-rectus repair of parastomal hernias. J Robot Surg 2018; 13:483-489. [DOI: 10.1007/s11701-018-0874-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 09/17/2018] [Indexed: 12/27/2022]
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Yang X, He K, Hua R, Shen Q, Yao Q. Laparoscopic repair of parastomal hernia. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:45. [PMID: 28251124 DOI: 10.21037/atm.2017.02.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Parastomal hernia is one of the most common long-term complications after abdominal ostomy. Surgical treatment for parastomal hernia is the only cure but a fairly difficult field because of the problems of infection, effects, complications and recurrence. Laparoscopic repair operations are good choices for Parastomal hernia because of their mini-invasive nature and confirmed effects. There are several major laparoscopic procedures for parastomal hernioplasty. The indications, technical details and complications of them will be introduced and discussed in this article.
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Affiliation(s)
- Xuefei Yang
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, the University of Hong Kong, Shenzhen 518053, China
| | - Kai He
- Hernia Center, Department of General Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Rong Hua
- Hernia Center, Department of General Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Qiwei Shen
- Hernia Center, Department of General Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Qiyuan Yao
- Hernia Center, Department of General Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
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Glasgow SC, Dharmarajan S. Parastomal Hernia: Avoidance and Treatment in the 21st Century. Clin Colon Rectal Surg 2016; 29:277-84. [PMID: 27582655 DOI: 10.1055/s-0036-1584506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Despite medical and surgical advances leading to increased ability to restore or preserve gastrointestinal continuity, creation of stomas remains a common surgical procedure. Every ostomy results in a risk for subsequent parastomal herniation, which in turn may reduce quality of life and increase health care expenditures. Recent evidence-supported practices such as utilization of prophylactic reinforcement, attention to stoma placement, and laparoscopic-based stoma repairs with mesh provide opportunities to both prevent and successfully treat parastomal hernias.
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Affiliation(s)
- Sean C Glasgow
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; USAF Center for the Sustainment of Trauma and Resuscitative Skills (C-STARS), St. Louis, Missouri
| | - Sekhar Dharmarajan
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; John Cochrane VA Medical Center, St. Louis, Missouri
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Modified laparoscopic Sugarbaker repair decreases recurrence rates of parastomal hernia. Surgery 2015; 158:954-9; discussion 959-61. [PMID: 26233810 DOI: 10.1016/j.surg.2015.04.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/26/2015] [Accepted: 04/28/2015] [Indexed: 01/04/2023]
Abstract
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.
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Praveen Raj P, Ganesh MK, Senthilnathan P, Parthasarathi R, Rajapandian S, Palanivelu C. Concomitant laparoscopic intraperitoneal onlay mesh repair with other clean contaminated procedures-study of feasibility and safety. J Laparoendosc Adv Surg Tech A 2014; 25:33-6. [PMID: 25531133 DOI: 10.1089/lap.2014.0001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Laparoscopic ventral hernia mesh repair has gained wide popularity with the benefits of shorter hospital stay, improved patient outcome, and fewer complications compared with traditional open procedures. It also offers the advantage of combining procedures at different quadrants of the abdomen. In this article we have retrospectively studied the safety of combining laparoscopic intraperitoneal onlay mesh (IPOM) repair with clean contaminated surgeries like cholecystectomy and hysterectomy. MATERIALS AND METHODS The data of all patients who received concomitant laparoscopic ventral hernia repairs along with cholecystectomy and hysterectomy were collected retrospectively. The details of these surgeries and the immediate postoperative outcome parameters were analyzed. RESULTS Between January 2006 and January 2011, 246 cases of laparoscopic IPOM in combination with clean contaminated surgeries were performed. Of these, 126 were hysterectomies, and 120 were cholecystectomies. Mean operating time for laparoscopic IPOM with cholecystectomy was 136 minutes (range, 112-172 minutes), and that for laparoscopic IPOM with hysterectomy was 224 minutes (range, 196-285 minutes). The average hospital stays were 4.3 days (range, 3-7 days) for laparoscopic IPOM with hysterectomy and 2.73 days (range, 1-5 days) for laparoscopic IPOM with cholecystectomy. Thirty-six patients (14.6%) developed seroma, for which 16 patients (6.5%) warranted aspiration. We had 0.8% mesh infection in total. The recurrence rates were 0.83% (n=1) in the cholecystectomy group and 0.8% (n=1) in the hysterectomy group. CONCLUSIONS Laparoscopic IPOM can be performed simultaneously with selected clean contaminated surgeries with acceptable morbidity. Combining clean contaminated surgeries does not significantly alter the outcome of the procedure.
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Affiliation(s)
- Palanivelu Praveen Raj
- Department of Surgical Gastroenterology, Gem Hospital & Research Centre , Coimbatore, Tamil Nadu, India
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Gillern S, Bleier JIS. Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials. Clin Colon Rectal Surg 2014; 27:162-71. [PMID: 25435825 DOI: 10.1055/s-0034-1394090] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Suzanne Gillern
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Al Shakarchi J, Williams JG. Systematic review of open techniques for parastomal hernia repair. Tech Coloproctol 2014; 18:427-32. [PMID: 24448678 DOI: 10.1007/s10151-013-1110-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/16/2013] [Indexed: 11/29/2022]
Abstract
Parastomal hernia formation is common following formation of an abdominal stoma, with the risk of subsequent incarceration, obstruction and strangulation. Current treatment options include non-operative management, stoma relocation and fascial repair with or without mesh. The purpose of this systematic review was to evaluate the effectiveness and safety of open mesh repair of a parastomal hernia and to compare open non-mesh fascial repair with mesh techniques of parastomal hernia repair. Electronic databases were searched for studies comparing the two surgical techniques in accordance with preferred reporting items for systematic reviews and meta-analyses. The primary outcome of the study was the comparison of recurrence rates of parastomal hernia for each technique. Secondary outcomes included comparison of mortality, wound infection, mesh infection and any other complication. Twenty-seven studies of parastomal hernia repair were included and divided into two subgroups for open mesh repair and non-mesh fascial repair. Non-mesh fascial repair resulted in a high recurrence rate (around 50%). Reported recurrence rates for mesh repair were substantially lower, at 7.9-14.8%, depending on the position of the mesh in relation to the abdominal fascia and the length of follow-up. Morbidity and mortality did not differ significantly between the techniques used to repair a parastomal hernia. This study shows that mesh repair of a parastomal hernia is safe and significantly reduces the rate of recurrence compared with sutured repair, which should only be used in exceptional circumstances. There is insufficient evidence to determine which mesh technique (onlay, sublay or underlay) is most successful in terms of recurrence rates and morbidity.
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Affiliation(s)
- J Al Shakarchi
- Department of Surgery, Sandwell Hospital, West Bromwich, UK,
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Abstract
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.
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Affiliation(s)
- Nilay R Shah
- Department of Surgery, Mayo Clinic Hospital, 5777 East Mayo Boulevard, MCSB SP 3-522 Gen Surg, Phoenix, AZ 85054, USA
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Zia K, McGowan DR, Moore E. Laparoscopic fascial suture repair of parastomal hernia. BMJ Case Rep 2013; 2013:bcr-2013-010162. [PMID: 23780775 DOI: 10.1136/bcr-2013-010162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Khawaja Zia
- Department of General Surgery, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
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Abstract
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.
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Abstract
The overall incidence of parastomal hernias is 35-50%. Different methods of hernia repairs (local fascial repair, stoma relocation and various types of mesh repairs) did not provide satisfactory results. Laparoscopic approach makes peristomal incision unnecessary and decreases the potential risk of mesh infection as well. In spite of all attempts the incidence of recurrent parastomal hernias is as high as 12-35%. These unsatisfactory results supported the idea of mesh implantation at the time of the initial stoma formation. In this study the authors inserted a self-designed two-layered special meshin 17 cases as a prevention and after 5 years follow-up period no parastomal hernias were recorded. The only complication noted was a minor stricture on the surface of the skin, that could have easily been corrected. Therefore, the authors support the idea of preventive mesh insertion at time of definitive stoma formation.
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Affiliation(s)
- Attila Nagy
- Veszprém Megyei Csolnoky Ferenc Kórház Általános Sebészeti Osztály 8200 Veszprém Kórház u. 1.
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Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011:CD007781. [PMID: 21412910 DOI: 10.1002/14651858.cd007781.pub2] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse. OBJECTIVES We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia. SEARCH STRATEGY We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand. SELECTION CRITERIA We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD). MAIN RESULTS We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I(2) = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I(2)= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs. AUTHORS' CONCLUSIONS The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.
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Affiliation(s)
- Stefan Sauerland
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care (IQWiG), Dillenburger Str. 27, Cologne, Germany, 51105
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Abstract
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.
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Affiliation(s)
- D Berger
- Klinik für Viszeral-, Gefäss- und Kinderchirurgie, Stadtklinik, Baden-Baden, Deutschland.
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Slater NJ, Hansson BME, Buyne OR, Hendriks T, Bleichrodt RP. Repair of parastomal hernias with biologic grafts: a systematic review. J Gastrointest Surg 2011; 15:1252-8. [PMID: 21360207 PMCID: PMC3116129 DOI: 10.1007/s11605-011-1435-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 01/26/2011] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Nicholas Jonathan Slater
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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García-Vallejo L, Concheiro P, Mena E, Baltar J, Baamonde I, Folgar L. Parastomal hernia repair: laparoscopic ventral hernia meshplasty with stoma relocation. The current state and a clinical case presentation. Hernia 2010; 15:85-91. [PMID: 20084419 DOI: 10.1007/s10029-009-0617-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 12/22/2009] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- L García-Vallejo
- Department of Surgery, Hospital de Conxo, Complejo Hospitalario Universitario de Santiago, C/Ramón Baltar, s/n. 15706, Santiago de Compostela, Spain.
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Berger D, Bientzle M. Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair! A prospective, observational study with 344 patients. Hernia 2008; 13:167-72. [PMID: 18853228 DOI: 10.1007/s10029-008-0435-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 09/17/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND Today, the laparoscopic approach is a standard procedure for the repair of incisional hernias. However, the direct contact of visceral organs with mesh material is a major issue. PATIENTS AND METHODS This prospective observational study presents the data of 344 patients treated for incisional and parastomal hernias with a new mesh made of polyvinylidene fluoride (PVDF; Dynamesh IPOM) between May 2004 and January 2008 with a minimum follow-up of 6 months. The median follow-up of 297 patients after incisional hernias totaled 24 months and 20 months for 47 patients with parastomal hernias. Incisional hernias were repaired using an IPOM technique. For parastomal hernias, a recently described sandwich technique was used with two meshes implanted in an intraperitoneal onlay position. RESULTS The recurrence rate for incisional hernias was 2/297 = 0.6% and 1/47 = 2% for parastomal hernias. Three patients developed a secondary infection after surgical revision or puncture of a seroma. One patient had a bowel fistula through the mesh, with an abscess in the hernia sac. In all cases, the infection healed and the mesh could be preserved. No long-term mesh-related complications have been observed. CONCLUSION The laparoscopic repair of incisional and parastomal hernias with meshes made of PVDF (Dynamesh IPOM) revealed low recurrence and, overall, low complication rates. Especially in cases of infection, the material proved to be resistant without clinical signs of persistent bacterial contamination. Mesh-related complications did not occur during the follow-up.
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Affiliation(s)
- D Berger
- Department of Surgery, Stadtklinik, Balgerstrasse 50, 76532 Baden-Baden, Germany.
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Prevention of parastomal hernia by the placement of a mesh at the primary operation. Hernia 2008; 12:577-82. [PMID: 18523836 DOI: 10.1007/s10029-008-0387-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 04/29/2008] [Indexed: 10/22/2022]
Abstract
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.
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