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

End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches

INTRODUCTION

Parastomal hernia (PSH) is the most common and challenging complication after stoma creation, with an estimated 50% incidence 2 years after the index surgery. Mesh repair is the treatment of choice. Laparoscopic and/or robotic approaches allow acceptable outcomes.

MATERIALS AND METHODS

A systematic literature review from January 2012 to November 2023 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Embase, PubMed, and Scopus search were performed to select articles dealing with minimally invasive surgical treatment for PSH after end colostomy.

RESULTS

603 studies were found, and 24 were chosen. When compared to open surgery, laparoscopy showed decreased postoperative complications and recurrence. The main laparoscopic approaches are the keyhole (KH), the Sugarbaker (SB), and the sandwich technique. Continuous improvement in surgery, mesh technology, and surgeons' expertise led to an amelioration of surgical outcome and recurrence rate after repair. Recent studies showed comparable outcomes for SB and KH techniques, while novel surgical approaches have been proposed in an attempt to further increase the operative and long-term results. Reports on PSH robotic repairs are scarce and describe small series results, suggesting a role of the initial learning curve as a risk factor for complications.

CONCLUSION

End-colostomy PSH surgical repair still represents a challenge for surgeons. Recent evidence has not shown a significant advantage in postoperative complications and recurrence with a specific repair among SB, KH, and sandwich technique. The paucity of data on robotic surgery does not allow to draw definitive conclusion. Further primary, multicentric, and larger cohort studies are needed.

Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach

Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.

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.

Prophylactic Mesh Placement During Formation of an End-colostomy: Long-term Randomized Controlled Trial on Effectiveness and Safety

OBJECTIVE

The aim of this study was to determine if prophylactic mesh placement is an effective, safe, and cost-effective procedure to prevent parastomal hernia (PSH) formation in the long term.

BACKGROUND

A PSH is the most frequent complication after stoma formation. Prophylactic placement of a mesh has been suggested to prevent PSH, but long-term evidence to support this approach is scarce.

METHODS

In this multicentre superiority trial patients undergoing the formation of a permanent colostomy were randomly assigned to either retromuscular polypropylene mesh reinforcement or conventional colostomy formation. Primary endpoint was the incidence of a PSH after 5 years. Secondary endpoints were morbidity, mortality, quality of life, and cost-effectiveness.

RESULTS

A total of 150 patients were randomly assigned to the mesh group (n = 72) or nonmesh group (n = 78). For the long-term follow-up, 113 patients were analyzed, and 37 patients were lost to follow-up. After a median follow-up of 60 months (interquartile range: 48.6-64.4), 49 patients developed a PSH, 20 (27.8%) in the mesh group and 29 (37.2%) in the nonmesh group ( P = 0.22; RD: -9.4%; 95% CI: -24, 5.5). The cost related to the meshing strategy was € 2.239 lower than the nonmesh strategy (95% CI: 491.18, 3985.49), and quality-adjusted life years did not differ significantly between groups ( P = 0.959; 95% CI: -0.066, 0.070).

CONCLUSIONS

Prophylactic mesh placement during the formation of an end-colostomy is a safe procedure but does not reduce the incidence of PSH after 5 years of follow-up. It does, however, delay the onset of PSH without a significant difference in morbidity, mortality, or quality of life, and seems to be cost-effective.

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.

Case of laparoscopic parastomal hernia repair using modified Sugarbaker mesh method

A 75-year-old woman underwent sigmoid colon resection and transverse colostomy for perforation of the diverticulum of the sigmoid colon at 70 years of age at another hospital. She was referred to our hospital with complaints of abdominal discomfort 3 months prior to presentation. Abdominal computed tomography revealed a parastomal hernia (PSH). We performed laparoscopic repair using the Sugarbaker approach with a Symbotex Composite Mesh™ and laparoscopic adhesive intestinal repair. The patient’s post-operative course was unremarkable, and she was transferred to the Department of Internal Medicine after 10 days. There was no recurrence 6 months after surgery. Tension-free surgery using a mesh has been reported to be effective in preventing the recurrence of PSH. We performed a laparoscopic modified Sugarbaker mesh method using the Symbotex Composite Mesh™ with collagen film to repair an abdominal hernia.

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair

BACKGROUND

In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available.

PURPOSE

The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS.

METHODS

Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n = 11) and with a ready-made specific mesh (SM, n = 22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant.

RESULTS

We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P = .2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P = 1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation.

CONCLUSION

In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

Preoperative Progressive Pneumoperitoneum and Botulinum Toxin Type A in Patients With Large Parastomal Hernia

Background: The combination of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BTA) in adjuvant treatment of large parastomal hernia (LPH) has not been reported in the previous literature.

Methods: From February 2018 to June 2019, 16 patients were diagnosed with LPH in our hospital were included in this study. All patients received PPP and BTA treatment to expand abdominal volume and extend abdominal muscle before surgery. The laparoscopic Sugarbaker method was preferred for defect close.

Results: Before and after PPP and BTA, the mean volume of the parastomal hernia (VPH) was 1,522 and 1,644 cc, respectively (P < 0.01), and the mean volume of the abdominal cavity (VAC) was 5,847 and 9,408 cc, respectively (P < 0.01). The VPH/VAC ratio was decreased by an average of 8.4% after the combination management. And the lateral abdominal muscle length was increased by an average of 4.8 cm/side (P < 0.01). These patients underwent surgery successfully, and no hernia recurrence after (17.6 ± 2.4) months of follow-up.

Conclusions: The combination of PPP and BTA effectively expand the abdominal volume, decrease the risk of abdominal compartment syndrome (ACS) postoperatively, and beneficial to laparoscopic repair of LPH.

Functionalized Strategies and Mechanisms of the Emerging Mesh for Abdominal Wall Repair and Regeneration

Meshes have been the overwhelmingly popular choice for the repair of abdominal wall defects to retrieve the bodily integrity of musculofascial layer. Broadly, they are classified into synthetic, biological and composite mesh based on their mechanical and biocompatible features. With the development of anatomical repair techniques and the increasing requirements of constructive remodeling, however, none of these options satisfactorily manages the conditional repair. In both preclinical and clinical studies, materials/agents equipped with distinct functions have been characterized and applied to improve mesh-aided repair, with the importance of mesh functionalization being highlighted. However, limited information exists on systemic comparisons of the underlying mechanisms with respect to functionalized strategies, which are fundamental throughout repair and regeneration. Herein, we address this topic and summarize the current literature by subdividing common functions of the mesh into biomechanics-matched, macrophage-mediated, integration-enhanced, anti-infective and antiadhesive characteristics for a comprehensive overview. In particular, we elaborate their effects separately with respect to host response and integration and discuss their respective advances, challenges and future directions toward a clinical alternative. From the vastly different approaches, we provide insight into the mechanisms involved and offer suggestions for personalized modifications of these emerging meshes.

Parastomal Hernia: A Retrospective Nationwide Cohort Study Comparing Different Techniques with Long-Term Follow-Up

BACKGROUND

Parastomal hernia repair is a complex surgical procedure with high recurrence and complication rates. This retrospective nationwide cohort study presents the results of different parastomal hernia repair techniques in Finland.

METHODS

All patients who underwent a primary end ostomy parastomal hernia repair in the nine participating hospitals during 2007-2017 were included in the study. The primary outcome measure was recurrence rate. Secondary outcomes were complications and re-operation rate.

RESULTS

In total, 235 primary elective parastomal hernia repairs were performed in five university hospitals and four central hospitals in Finland during 2007-2017. The major techniques used were the Sugarbaker (38.8%), keyhole (16.3%), and sandwich techniques (15.4%). In addition, a specific intra-abdominal keyhole technique with a funnel-shaped mesh was utilized in 8.3% of the techniques; other parastomal hernia repair techniques were used in 21.3% of the cases. The median follow-up time was 39.0 months (0-146, SD 35.3). The recurrence rates after the keyhole, Sugarbaker, sandwich, specific funnel-shaped mesh, and other techniques were 35.9%, 21.5%, 13.5%, 15%, and 35.3%, respectively. The overall re-operation rate was 20.4%, while complications occurred in 26.3% of patients.

CONCLUSION

The recurrence rate after parastomal hernia repair is unacceptable in this nationwide cohort study. As PSH repair volumes are low, further multinational, randomized controlled trials and hernia registry data are needed to improve the results.

Emergency laparoscopic treatment of complicated parastomal hernias

Parastomal hernia is not a rare event. Being by definition a complication of ostomy creation, a parastomal hernia also carries the risk of becoming symptomatic and complicated. At present, there are not enough solid data in literature to allow an evidence-based approach to this condition and to its possible complications, especially in the emergency setting. The aim of this paper is to describe through a narrative review of the literature the different surgical approaches concerning parastomal hernias. In order to exemplify the emergency complications we also present two cases in which the watchful waiting approach eventually led to the necessity of urgent surgical treatment, due to bowel incarceration into the parastomal hernia. We chose to tailor the surgical plan on the patient's anatomic and clinical condition, pursuing the laparoscopic approach with two different surgical technique (Sugarbaker and keyhole), each time estimated by the operating surgeon to be the more suitable option for the patient. We acknowledge that laparoscopy can be an optimal choice for the emergency and elective treatment of parastomal hernias, whenever an appropriate know-how is present.

Laparoscopic parastomal hernia repair delays recurrence relative to open repair

BACKGROUND

Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair.

METHODS

An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair.

RESULTS

Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively).

CONCLUSIONS

Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Parastomal Hernia Repair With 3-D Mesh Implants After Radical Cystectomy and Ileal Conduit Urinary Diversion - A Single-center Experience Using a Purpose Made Alloplastic Mesh Implant

OBJECTIVE

To report and evaluate our open surgical technique for the treatment of parastomal hernias (PSH) after ileal conduit urinary diversion and results using a specifically designed, three-dimensional intraperitoneal onlay mesh aiming to minimize PSH recurrence and perioperative complications.

METHODS

We retrospectively evaluated all patients who developed a PSH after ileal conduit urinary diversion and were treated with the 3-dimensional alloplastic IPST mesh at the Marien Hospital Herne, Ruhr-University Bochum, Germany between 01/2009 and 12/2015. As a surgical approach, we used a small, open incision in order to reduce the hernia sac and place the mesh. Subsequently, we performed a voluntary follow-up of the surviving patients to evaluate long-term recurrence and complication rates. In addition, we conducted a reassessment of the cross-sectional imaging available.

RESULTS

Between January 2009 and December 2015, 40 patients underwent hernia repair due to a clinically significant hernia. Out of those patients, 1 suffered from a postoperative wound infection. In total 27 patients participated in a voluntary follow-up with a median follow-up period of 29 months (IQR 16, 63 months). Follow-up examination revealed 2 cases of recurrent PSH (7, .4%), 2 patients who developed stoma stenosis (7.4%) and 5 patients who suffered from minor complications (18.5%).

CONCLUSION

Our localized open surgical approach using a 3-dimensional mesh implant presents an effective method of treating a PSH with a low complication and recurrence rate.

Modified laparoscopic Sugarbaker repair of parastomal hernia with a three-point anchoring technique

AIM

To retrospectively evaluate the safety and feasibility of a new modified laparoscopic Sugarbaker repair in patients with parastomal hernias.

METHODS

A retrospective study was performed to analyze eight patients who underwent parastomal hernia repair between June 2016 and January 2018. All of these patients received modified laparoscopic Sugarbaker hernia repair treatment. This modified technique included an innovative three-point anchoring and complete suturing technique to fix the mesh. All procedures were performed by a skilled hernia surgeon. Demographic data and perioperative outcomes were collected to evaluate the safety and efficacy of this modified technique.

RESULTS

Of these eight patients, two had concomitant incisional hernias. All the hernias were repaired by the modified laparoscopic Sugarbaker technique with no conversion to laparotomy. Three patients had in-situ reconstruction of intestinal stoma. The median mesh size was 300 cm², and the mean operative time was 205.6 min. The mean postoperative hospitalization time was 10.4 d, with a median pain score of 1 (visual analog scale method) at postoperative day 1. Two patients developed postoperative complications. One patient had a pocket of effusion surrounding the biologic mesh, and one patient experienced an infection around the reconstructed stoma. Both patients recovered after conservative management. There was no recurrence during the follow-up period (6-22 mo, average 13 mo).

CONCLUSION

The modified laparoscopic Sugarbaker repair could fix the mesh reliably with mild postoperative pain and a low recurrence rate. The technique is safe and feasible for parastomal hernias.

Surgical Management of Parastomal Hernias

Parastomal hernias are a common complication after ostomy formation that can require surgical repair when they become symptomatic. Operative planning and a thorough understanding of the anatomy of the abdominal wall are important. Simple fascial repair is associated with an unacceptably high recurrence rate and should be used as a temporary measure only. Stoma relocation has a high recurrence rate. Prophylactic mesh can and should be used. At this time, the use of mesh is considered the standard of care in the repair of parastomal hernias.

Clinical outcomes after parastomal hernia repair with a polyester monofilament composite mesh: a cohort study of 79 consecutive patients

PURPOSE

Different techniques and mesh materials are used in parastomal hernia repair with recently reported recurrence rates ranging from 10 to 28%. The aim of this cohort study was to examine the risk of recurrence and chronic pain after Sugarbaker or keyhole parastomal hernia repair with intraperitoneal placement of a polyester monofilament macroporous composite mesh.

METHODS

Data on all patients undergoing parastomal hernia repair with Parietex™ Composite Parastomal Mesh at our institution during a 4-year period were examined. Patients with urostomy were excluded. A team of three experienced surgeons performed all repairs. Follow-up including physical examination was done after 10 days, 6 and 12 months, and hereafter as annual structured telephone interviews. Patients suspected of hernia recurrence were offered computed tomography scan. Chronic pain was defined as pain requiring out-patient visit(s) and/or regular use of analgesics.

RESULTS

79 patients (Sugarbaker, n = 69; keyhole, n = 10) were included. Of those, 72 procedures were performed laparoscopically and seven by open technique. Two patients were reoperated within 30 days with removal of the mesh. In total, seven (9%) patients had parastomal hernia recurrence (reoperation, n = 3; conservative management, n = 4) during follow-up of median 12 months (range 0-49 months). In univariable logistic analyses, type of stoma was associated with recurrence (ileostomy 28% vs colostomy 3%, p = 0.007). Three patients (4%) reported chronic pain.

CONCLUSION

In this study, we found low rates of recurrence and chronic pain following parastomal hernia repair using intraperitoneal reinforcement with a polyester monofilament composite mesh.

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.

European Hernia Society guidelines on prevention and treatment of parastomal hernias

BACKGROUND

International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project.

METHODS

The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants.

RESULTS

End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed.

CONCLUSION

An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

Parastomal Hernia Repair with Intraperitoneal Mesh

Purpose

Parastomal hernia is a common complication following a stoma and may cause leakage or incarceration. No optimal treatment has been established, and existing methods using mesh repair are associated with high recurrence rates and a considerable risk for short- and long-term complications including death. A double-layer intraperitoneal on-lay mesh (IPOM), the Parastomal Hernia Patch (BARD™), consisting of ePTFE and polypropylene, has been developed and tailored to avoid recurrence. To evaluate the safety of and recurrence rate using this mesh, a nonrandomised prospective multicentre study was performed.

Method

Fifty patients requiring surgery for parastomal hernia were enrolled. Clinical examination and CT scan prior to surgery were performed. All patients were operated on using the Parastomal Hernia Patch (BARD). Postoperative follow-up at one month and one year was scheduled to detect complications and hernia recurrence.

Results

The postoperative complication rate at one month was 15/50 (30%). The parastomal hernia recurrence rate at one year was 11/50 (22%). The reoperation rate at one month was 7/50 (14%), and further 5/50 (10%) patients were reoperated on during the following eleven months.

Prophylactic Mesh Placement During Formation of an End-colostomy Reduces the Rate of Parastomal Hernia: Short-term Results of the Dutch PREVENT-trial

OBJECTIVE

The aim of this study was to investigate the incidence of parastomal hernias (PSHs) after end-colostomy formation using a polypropylene mesh in a randomized controlled trial versus conventional colostomy formation.

BACKGROUND

A PSH is the most frequent complication after stoma formation. Symptoms may range from mild abdominal pain to life-threatening obstruction and strangulation. The treatment of a PSH is notoriously difficult and recurrences up to 20% have been reported despite the use of mesh. This has moved surgical focus toward prevention.

METHODS

Augmentation of the abdominal wall with a retro-muscular lightweight polypropylene mesh was compared with the traditional formation of a colostomy. In total, 150 patients (1:1 ratio) were included. The incidence of a PSH, morbidity, mortality, quality of life, and cost-effectiveness was measured after 1 year of follow-up.

RESULTS

There was no difference between groups regarding demographics and predisposing factors for PSH. Three out of 67 patients (4.5%) in the mesh group and 16 out of 66 patients (24.2%) in the nonmesh group developed a PSH (P = 0.0011). No statistically significant difference was found in infections, concomitant hernias, SF-36 questionnaire, Von Korff pain score, and cost-effectiveness between both study groups.

CONCLUSION

Prophylactic augmentation of the abdominal wall with a retromuscular lightweight polypropylene mesh at the ostomy site significantly reduces the incidence of PSH without a significant difference in morbidity, mortality, quality of life, or cost-effectiveness.

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.

Prophylactic mesh to prevent parastomal hernia after end colostomy: a meta-analysis and trial sequential analysis

PURPOSE

Prevention of parastomal hernia (PSH) formation is crucial, given the high prevalence and difficulties in the surgical repair of PSH. To investigate the effect of a preventive mesh in PSH formation after an end colostomy, we aimed to meta-analyze all relevant randomized controlled trials (RCTs).

METHODS

We searched five databases. For each trial, we extracted risk ratios (RRs) of the effects of mesh or no mesh. The primary outcome was incidence of PSH with a minimum follow-up of 12 months with a clinical and/or computed tomography diagnosis. RRs were combined using the random-effect model (Mantel-Haenszel). To control the risk of type I error, we performed a trial sequential analysis (TSA).

RESULTS

Seven RCTs with low risk of bias (451 patients) were included. Meta-analysis for primary outcome showed a significant reduction of the incidence of PSH using a mesh (RR 0.43, 95% CI 0.26-0.71; P = 0.0009). Regarding TSA calculation for the primary outcome, the accrued information size (451) was 187.1% of the estimated required information size (RIS) (241). Wound infection showed no statistical differences between groups (RR 0.77, 95% CI 0.39-1.54; P = 0.46). PSH repair rate showed a significant reduction in the mesh group (RR 0.28 (95% CI 0.10-0.78; P = 0.01).

CONCLUSIONS

PSH prevention with mesh when creating an end colostomy reduces the incidence of PSH, the risk for subsequent PSH repair and does not increase wound infections. TSA shows that the RIS is reached for the primary outcome. Additional RCTs in the previous context are not needed.

[Prevention of paracolostomic hernia]

AIM

To improve the prevention of paracolostomic hernias.

MATERIAL AND METHODS

We studied the prevention of paracolostomic hernia using mesh allograft. The study involved 73 patients with low-ampullary rectal cancer. Open or laparoscopic abdominoperineal extirpation of rectum was performed in all observations. 21 patients underwent prophylactic Sugarbaker's repair of paracolostomic area. We used the modifications of this surgical stage for transabdominal and retroperitoneal stoma.

RESULTS

There were no postoperative complications associated with the use of allograft. The hernia occurred in one case (4.8%) of prevention group and in 14 (26.9%) patients of control group.

CONCLUSION

The first results of composite allograft application to prevent paracolostomic hernias are encouraging. The absence of specific complications and favorable long-term results allow to continue the investigation.

Prophylactic Mesh Application during Colostomy to Prevent Parastomal Hernia: A Meta-Analysis

Background. Parastomal hernia is a common complication after stoma formation, especially in permanent colostomy. The present meta-analysis aimed to evaluate the effectiveness of prophylactic mesh application during permanent colostomy for preventing parastomal hernia. Methods. Randomized controlled trials comparing outcomes in patients who underwent colostomy with or without prophylactic mesh application were identified from PubMed, EMBASE, Science Citation Index, and the Cochrane Libraries. Results. This meta-analysis included 8 randomized controlled trials with 522 participants. Our pooled results showed that prophylactic mesh application (mesh group) reduced the incidence of clinically detected parastomal hernia (risk ratio [RR]: 0.22; 95% confidence interval [CI]: 0.13-0.38; P < 0.00001), radiologically detected parastomal hernia (RR: 0.62; 95% CI: 0.47-0.82; P = 0.0008), and surgical repair for herniation (RR: 0.34; 95% CI: 0.14-0.83; P = 0.02) when compared with conventional permanent colostomy formation (control group). The incidence of complications, including wound infection, peristomal infection, mesh infection, stomal necrosis and stenosis, stoma site pain, and fistula, was not higher in the mesh group than in the control group. Conclusions. Our meta-analysis demonstrated that prophylactic mesh application at the time of primary colostomy formation is a promising method for the prevention of parastomal herniation.

Parastomal Hernia: Avoidance and Treatment in the 21st Century

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.

Systematic Review and Meta-Analysis of Extraperitoneal Versus Transperitoneal Colostomy for Preventing Parastomal Hernia

BACKGROUND

Parastomal hernia remains a frequent problem after constructing a colostomy. Current research mainly focuses on prophylactic mesh placement as an addition to transperitoneal colostomies. However, for constructing a colostomy, either an extraperitoneal or transperitoneal route can be chosen.

OBJECTIVE

The aim of this meta-analysis was to investigate which technique results in lower parastomal hernia rates in patients undergoing end colostomy.

DATA SOURCES

A meta-analysis was conducted according to Preferred Items for Reporting of Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane, PubMed, and Google Scholar databases were searched. The study protocol was registered in the International Prospective Register of Systematic Reviews database.

STUDY SELECTION

Studies comparing extraperitoneal and transperitoneal colostomies were included. Only studies written in English were included. The quality of studies and risk of bias were assessed using the Cochrane risk-of-bias tool. The quality of nonrandomized studies was assessed using the Newcastle-Ottawa Scale.

INTERVENTION

The intervention was colostomy formation.

MAIN OUTCOME MEASURES

The main outcome measure was parastomal hernia incidence. Secondary outcome measures were stoma prolapse, stoma necrosis, and operating time.

RESULTS

Of 401 articles found, a meta-analysis was conducted of 10 studies (2 randomized controlled trials and 8 retrospective studies) composed of 1048 patients (347 extraperitoneal and 701 transperitoneal). Extraperitoneal colostomy led to significantly lower parastomal hernia rates (22 of 347 (6.3%) for extraperitoneal versus 125 of 701 (17.8%) for transperitoneal; risk ratio = 0.36 (95% CI, 0.21-0.62); I = 26%; p < 0.001) and significantly lower stoma prolapse rates (2 of 185 (1.1%) for extraperitoneal versus 13 of 179 (7.3%) for transperitoneal; risk ratio = 0.21 (95% CI, 0.06-0.73); I = 0%; p = 0.01). Differences in stoma necrosis were not significant. Operating time data were insufficient to analyze.

LIMITATIONS

Most of the studies were nonrandomized, and some were not recent publications.

CONCLUSIONS

Although the majority of studies included were retrospective, extraperitoneal colostomy was observed to lead to a lower rate of parastomal hernia and stoma prolapse.

Changes in the Surgical Management of Parastomal Hernias Over 15 Years: Results of 135 Cases

BACKGROUND

Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures.

METHODS

From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences.

RESULTS

One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12-146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured.

CONCLUSION

The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p < 0.001).

Laparoscopic modified Sugarbaker parastomal hernia repair with 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh technique

BACKGROUND

The ideal mesh and mesh fixation technique for laparoscopic Sugarbaker (SB) parastomal hernia repair have not yet been identified.

METHODS

Sixteen patients with parastomal hernia who underwent laparoscopic modified SB repair (LSB) between June 2012 and October 2015 were retrospectively analyzed. LSB was performed using a developed standardized 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh (PCO-PM) technique.

RESULTS

Out of 16 cases, 14 were primary and 2 recurrent hernias; 13 were para-end colostomy and 3 were para-ileal conduit (PIC) hernias. The median longitudinal and transverse diameters of the hernia orifice were 5 cm (2.5-7 cm) and 4.2 cm (2-6 cm), respectively. Five cases had a concomitant midline incisional hernia, which was simultaneously repaired. In all cases, the mesh was placed without deflection. The median operation time was 193 (75-386) min. Perioperative complications occurred in two cases (13 %) with PIC, one intra-operatively and the other postoperatively. The intra-operative complication was enterotomy close to the ureteroenteric anastomosis of the ileal conduit; it was repaired through a mini-laparotomy. LSB was accomplished without any subsequent postoperative complications. The postoperative complication was ureteral obstruction that required creation of nephrostomy. Mini-laparotomy was necessary in those two cases (13 %) because of intra-operative enterotomy and severe intra-abdominal adhesions. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed with a median follow-up of 14.5 (2-41) months.

CONCLUSIONS

Our LSB using standardized mesh fixation technique is safe and feasible, and the PCO-PM seems to be the most optimal prosthesis.

Long-term assessment of parastomal hernia prevention by intra-peritoneal mesh reinforcement according to the modified Sugarbaker technique

BACKGROUND

Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of that study is to assess the safety and the long-term efficacy of an intra-peritoneal onlay mesh (IPOM) positioned at the time of primary stoma formation to prevent PSH occurrence.

MATERIALS AND METHODS

That multicentre prospective study concerned 29 consecutive patients operated for cancer of the low rectum between 2008 and 2014. There were 14 men and 15 women with a median age of 73 years (range 39-88) and a BMI of 28 (range 21-43). All the patients had potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round non-slit composite mesh centred on the stoma site and covering the lateralized colon according to the modified Sugarbaker technique. The major outcomes analysed were operative time, complications related to mesh and PSH incidence. Patients were evaluated at 6-month intervals for the first 2 years and thereafter annually with physical examination and CT scan control. For PSH evaluation, we used the classification of Moreno-Matias.

RESULTS

Surgery was performed by laparoscopy in 24 patients and by laparotomy in 5; 17 had a trans-peritoneal colostomy and 12 an extra-peritoneal colostomy. The median size of the mesh was 15 cm (range 12-20), the operative time 225 min. (range 123-311) and the specific time for mesh placement 15 min. (range 10-30). With a median follow-up of 48 months (range 6-88), no mesh infection or complication requiring mesh removal were recorded. No patient developed a true PSH; two of them had a type Ia PSH (only containing the bowel forming the colostomy with a sac < 5 cm) and were totally asymptomatic.

CONCLUSION

In our series, the incidence of PSH was 7 % and no specific mesh-related complication was noted. Prophylactic mesh reinforcement according to the modified Sugarbaker is an effective technique that addresses the issues related to the occurrence of PSH.

Single-port parastomal hernia repair by using 3-D textile implants

Background:

Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall.

Methods:

We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications.

Results:

From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively.

Conclusion:

We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.

Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy

BACKGROUND

Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce.

OBJECTIVE

The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection.

DESIGN

This is a prospective, multicenter, randomized controlled clinical trial.

SETTINGS

This study was conducted at 2 university and 3 central Finnish hospitals.

PATIENTS

From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined.

INTERVENTIONS

In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma.

MAIN OUTCOME MEASURES

The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures.

RESULTS

Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups.

LIMITATIONS

The study was limited by its small size and short follow-up time.

CONCLUSIONS

Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.

Modified laparoscopic Sugarbaker repair decreases recurrence rates of parastomal hernia. Surgery. 2015;158:954-959; discussion 959-961. [PMID: 26233810 DOI: 10.1016/j.surg.2015.04.052]

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.

Current state of laparoscopic parastomal hernia repair: A meta-analysis

AIM: To evaluate the efficacy and safety of the laparoscopic approaches for parastomal hernia repair reported in the literature.

METHODS: A systematic review of PubMed and MEDLINE databases was conducted using various combination of the following keywords: stoma repair, laparoscopic, parastomal, and hernia. Case reports, studies with less than 5 patients, and articles not written in English were excluded. Eligible studies were further scrutinized with the 2011 levels of evidence from the Oxford Centre for Evidence-Based Medicine. Two authors reviewed and analyzed each study. If there was any discrepancy between scores, the study in question was referred to another author. A meta -analysis was performed using both random and fixed-effect models. Publication bias was evaluated using Begg’s funnel plot and Egger’s regression test. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications. Studies were grouped by operative technique where indicated. Except for recurrence, most postoperative morbidities were reported for the overall cohort and not by approach so they were analyzed across approach.

RESULTS: Fifteen articles with a total of 469 patients were deemed eligible for review. Most postoperative morbidities were reported for the overall cohort, and not by approach. The overall postoperative morbidity rate was 1.8% (95%CI: 0.8-3.2), and there was no difference between techniques. The most common postoperative complication was surgical site infection, which was seen in 3.8% (95%CI: 2.3-5.7). Infected mesh was observed in 1.7% (95%CI: 0.7-3.1), and obstruction requiring reoperation also occurred in 1.7% (95%CI: 0.7-3.0). Other complications such as ileus, pneumonia, or urinary tract infection were noted in 16.6% (95%CI: 11.9-22.1). Eighty-one recurrences were reported overall for a recurrence rate of 17.4% (95%CI: 9.5-26.9). The recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, whereas the recurrence rate was 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

CONCLUSION: Laparoscopic intraperitoneal mesh repair is safe and effective for treating parastomal hernia. A modified Sugarbaker approach appears to provide the best outcomes.

Laparoscopic parastomal hernia repair: No different than a laparoscopic ventral hernia repair?

BACKGROUND

Parastomal hernia (PH) is a common complication when a stoma is used. The high incidence (35-50%) and patient longevity have created a situation where patients are being referred for consideration of repair with more frequency. Due to the presence of an ostomy and the increased bacterial contamination of the area, the insertion of a prosthetic material is concerning for complications. Laparoscopic repair of parastomal hernias utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes. The purpose of this study is to demonstrate that laparoscopic PH repair has outcomes similar to laparoscopic ventral hernia (LVH) repair without the presence of a stoma.

METHODS

After obtaining institutional review board approval, patients with parastomal hernia who underwent laparoscopic repair using Sugarbaker technique between 2009 and 2012 were compared to patients with ventral hernias who underwent LVH repair in a retrospective review, with a match of 1:3. Data collected included demographics, comorbidities, operative time, defect size, and mesh size. Outcomes and complications were compared between the two groups.

RESULTS

Twenty patients underwent Sugarbaker repair, and these cases were compared to 60 patients with ventral hernia that received LVH repair. There was no statistically significant difference in age, BMI, smoking status, ASA score, defect size, or mesh size between groups. Operative time was significantly longer in the PH group: 172 ± 35 versus the LVH group: 94 ± 32 min (p < 0.1). Length of stay was longer, 3 days (3-5.5) for PH versus 1 day (1-2.8) for LVH, p < 0.1. The two groups did not differ in terms of wound complications or recurrence, with a median follow-up of 37 days (IQ range 27-518).

CONCLUSION

The Sugarbaker technique is as safe as LVH repair with no more complications given the presence of a stoma.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.