Laparoscopic Repair of Parastomal Hernias

Published on 09/04/2015 by admin

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Last modified 09/04/2015

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Chapter 4 Laparoscopic Repair of Parastomal Hernias image

Alan A. Saber, MD, FACS

1 Clinical Anatomy

1 Types of Parastomal Hernias

Parastomal hernia has been anatomically classified into four subtypes: (Fig. 4-1)

1. Subcutaneous: The hernia sac goes alongside the stoma into the subcutaneous tissue. This is the most common type of paracolostomy hernia.
2. Interstitial: The hernia sac is within the layers of the abdominal wall. This hernia is at a high risk for strangulation.
3. Peristomal: The bowel prolapses through a circumferential hernia sac enclosing the stoma.
4. Intrastomal: The hernia sac is between the intestinal wall and the everted intestinal layer.
image

Figure 4-1

2 Characteristics of the Facial Defect

image Most hernia defects are lateral to the rectus abdominis muscle, alongside the mesentery of the emerging bowel, and medially and cranially to the stoma loop.
image Commonly the parastomal hernia sac is very large with a relatively small fascial defect.

2 Preoperative Considerations

image The life expectancy of the patient and any predisposing factors, such as malignancy and obesity, should influence the decision to proceed with surgery.
image Accurate diagnosis and assessment of the anatomy of the hernia are essential. This is done with clinical examination, or more accurately, with a computed tomography (CT) scan.
image CT scan is useful to delineate parastomal defects, any associated incisional hernia, and the content of the hernia (Fig. 4-2).
image A preoperative bowel preparation may diminish the risk of infection if there is a colonic injury during laparoscopy.
image Intravenous prophylactic antibiotic therapy covering both skin and intestinal flora is initiated.
image A large Foley catheter may be inserted into the stoma to facilitate location of the bowel intraoperatively.
image Seal the skin and stoma from the operative field with adhesive plastic drapes after preparing the skin.
image

Figure 4-2

3 Operative Steps

There are two techniques for laparoscopic repairs of parastomal hernias: the keyhole and the Sugarbaker techniques. Keyhole technique may be associated with bowel herniation between the mesh hole and the stoma loop. We have developed a technique that closes the gap between the mesh and the stoma loop and facilitates intracorporeal mesh manipulations (Scroll technique) during keyhole repairs. The Sugarbaker technique avoids the risk of herniation through the keyhole, but it does create an acute angle as the bowel exits the mesh and can cause obstruction (see Fig. 4-11). Meticulous attention to the details of mesh fixation and placement can limit these complications.

image 1 Laparoscopic Parastomal Hernia Repair Technique: The Scroll Technique

image Operating Room Setup (Fig. 4-3)

image The patient is placed in the supine position with the arms extended laterally.
image The surgeon and the assistant stand contralateral to the stoma site.
image General anesthesia is administered.
image The abdomen is prepared and draped, including the colostomy, in standard fashion; the stoma is covered with transparent adhesive drapes. Placement of a Foley catheter in the stoma is optional.
image

Figure 4-3

image Trocar Placement (Fig. 4-4)

image For a left lower quadrant stoma, an initial 12-mm Hasson trocar is placed in the right upper quadrant away from the hernia defect.
image Initial diagnostic laparoscopy usually reveals abdominal adhesions and the parastomal hernia.
image Under direct vision, two 5-mm trocars are inserted into the right lower quadrant.
image All the trocars are placed away from the hernia defect to facilitate surgical manipulation.
image

Figure 4-4

image Lysis of Adhesions

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