The Role of Mesh Implants in Surgical Treatment of Parastomal Hernia

Robotic parastomal hernia repair: an updated systematic review

INTRODUCTION

Parastomal hernias (PSH) are a frequent complication following ostomy surgery, often requiring surgical intervention. Robotic surgery offers potential advantages in PSH repair, but evidence on its efficacy remains limited. This systematic review evaluates the outcomes of different robotic PSH repair techniques.

EVIDENCE ACQUISITION

A systematic search of PubMed, Embase, and Cochrane databases was conducted (2015-2024) to identify studies on robotic PSH repair. Fourteen studies (13 retrospective, two prospective) met the inclusion criteria after screening 324 articles.

EVIDENCE SYNTHESIS

Data on patient demographics, surgical techniques, complications, recurrence rates, and follow-up duration were extracted. The analysis included 355 patients with a median follow-up of 12 months. Early studies focused on feasibility and safety, with subsequent research refining specific techniques like the Sugarbaker, Pauli, and keyhole repairs. Reported recurrence rates ranged from 0% to 9.5% across these techniques. However, 30-day complication rates varied significantly (0% to 50%), highlighting the need for standardized reporting and patient selection criteria. While some studies demonstrated low recurrence rates with acceptable complication profiles, others revealed higher complication rates, potentially related to specific techniques or patient factors. The emergence of variations within the Sugarbaker technique, such as the retromuscular approach with transversus abdominis release (TAR), demonstrates ongoing innovation in robotic PSH repair.

CONCLUSIONS

Robotic PSH repair shows promise, but further research is needed to confirm its long-term efficacy and cost-effectiveness.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic parastomal hernia repair in Ileal-conduit patients: short-term results in a single-center cohort study

PURPOSE

To describe and evaluate safety and feasibility of the robotic modified Sugarbaker technique with intraperitoneal underlay mesh (IPUM) for repairing parastomal hernias associated with ileal conduits (ICPSH).

METHODS

This retrospective, single-center cohort study analyzed data from 15 adult patients who underwent robotic ICPSH repair using the modified Sugarbaker IPUM technique between July 2021 and July 2023. The primary endpoints were hernia recurrence rates and 30-day morbidity. Secondary endpoints included length of stay, conversion to open surgery, 30-day readmission, and 30-day reoperation.

RESULTS

The mean patient age was 69.1 years, and 53.3% were female. Most patients (86.6%) had undergone radical cystectomy as the index surgery. The mean operative time was 249 min, with no conversions to open surgery. The 30-day complication rate was 26.7%, and the mean hospital stay was 3.6 days. No hernia recurrences, hydronephrosis, rise in creatinine or distended conduit on imaging suggesting poor drainage were observed during a mean follow-up of 15.2 months.

CONCLUSIONS

The robotic modified Sugarbaker IPUM technique appears safe and feasible for PSH repair in IC patients, with promising short-term outcomes. Further studies with larger cohorts and longer follow-up are needed to confirm its long-term efficacy and establish its role in ICPSH management.

Robotic parastomal hernia repair: A single-center cohort study

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

Establishment and evaluation of rat models of parastomal hernia

PURPOSE

Parastomal hernia poses a challenging problem in the field of hernia surgery. The high incidence and recurrence rates of parastomal hernia necessitate surgeons to enhance surgical techniques and repair materials. This study aimed to develop a rat model of parastomal hernia by inducing various types of defects on the abdominal wall with colostomy. This established method has potential for future studies on parastomal hernia.

METHODS

In this study, 32 male rats were included and randomly divided into four groups: the oblique abdominis excision (OE), oblique abdominis dissection (OD), rectus abdominis excision (RE), and rectus abdominis dissection (RD) groups. In each group, colostomy was performed and an abdominal wall defect was induced. The rats were observed for 28 days following surgery. The survival rate, body weight, parastomal hernia model scores, abdominal wall adhesion and inflammation, and collagen level in the hernial sac were compared.

RESULTS

No significant differences in survival rate and weight were observed among the four groups. The parastomal hernia model scores in the RE and RD groups were significantly higher than those in the OE and OD groups. The ratio of collagen I/III in the RE and RD groups was significantly lower than that in the OE and OD groups. Adhesion and inflammation levels were lower in the RE group than in the RD group.

CONCLUSION

Based on a comprehensive comparison of the findings, RE with colostomy emerged as the optimal approach for establishing parastomal hernia models in rats.

Design of New Concept of Knitted Hernia Implant

A knitted implant, unilaterally modified with plasma-assisted chemical-vapor deposition (PACVD), and with a nano-layer of fluorine derivative supplementation, for reducing the risk of complications related to adhesions, and the formation of a thick postoperative scar was prepared. The biological evaluation of designed or modified medical devices is the main aspect of preclinical research. If such studies use a medical device with prolonged contact with connective tissue (more than 30 days), biocompatibility studies require a safety assessment in terms of toxicity in vitro and in vivo, allergenicity, irritation, and cancerogenicity, reproductive and developmental toxicity. The ultimate aspect of biological evaluation is biofunctionality, and evaluation of the local tissue response after implantation, resulting in the determination of all aspects of local biocompatibility with the implemented synthetic material. The implantation of PACVD-modified materials in muscle allows us to estimate the local irritation effect on the connective tissue, determining the risk of scar formation, whereas implantation of the above-mentioned knitted fabric into the abdominal wall, assists with evaluating the risk of fistula formation-the main post-surgical complications. The research aimed to evaluate the local reaction of the soft tissues after the implantation of the knitted implants modified with PACVD of the fluoropolymer in the nanostuctural form. The local effect that occurred during the implantation of the designed implants was quantitatively and qualitatively evaluated when PACVD unmodified (reference), and modified medical devices were implanted in the abdominal cavity (intra-abdominal position) for 12 or into the muscles for 56 weeks. The comparative semi-quantitative histological assessment included the severity of inflammatory cells (multinucleated cells, lymphocytes, plasma cells, macrophages, giant cells) and the tissue response (necrosis, neovascularization, fibrosis, and fat infiltration) on a five-point scale. The knitted implants modified by PACVD did not indicate cumulative tissue response when they were implanted in the muscle and intra-abdominally with direct contact with the viscera. They reduced local tissue reaction (score -2.71 after 56 weeks of the implantation) and internal organ adhesion (irritation score -2.01 and adhesion susceptibility -0.3 after 12 weeks of the implantation) compared with the reference (unmodified by PACVD) knitted implant, which had an identical structure and was made of the same source.