Laparoscopic Repair of Parastomal Hernias

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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

image Lysis of adhesions is the most challenging part of this procedure; this is performed using sharp or blunt dissection as close as possible to the anterior abdominal wall.
image An energy source can be used only after ensuring no bowel is nearby to avoid lateral thermal injury.
image The hernia contents are reduced by a combination of external pressure and internal traction.
image One of the most challenging aspects of this type of laparoscopic repair is that one loop of bowel must remain on the abdominal wall. This can be difficult to differentiate with laparoscopic visualization. As mentioned, a Foley catheter, or occasionally, intraoperative endoscopy can guide the surgeon.
image The hernia margins are demarcated and measured, either extracorporeally or preferably intracorporeally, to determine the size of the mesh that would allow 5 cm of overlap circumferentially.

image Mesh Choice and Preparation (Figs. 4-5 and 4-6)

image We typically use ePTFE mesh (Dualmesh Plus, W.L. Gore). The lack of ingrowth on the peritoneal side is particularly advantageous when placing prosthetic mesh around the bowel.
image

Figure 4-5

image

Figure 4-6

image Keyhole Technique

image The mesh is fashioned by creating a 3 × 3 cm cruciate cut at the junction of two thirds and one third of the mesh (see Fig. 4-5).
image A split is made from the defect to the edge of the mesh.
image Long CV-0 nonabsorbable sutures are placed at each corner of the mesh and tied.
image The sutures are tied with the knot toward the rough surface of the mesh.
image The mesh is rolled tightly from each side to the middle like a scroll so that the rough surface of the mesh faces outward with sutures inside the rolled mesh. 2-0 Vicryl stay sutures are placed around the rolled mesh to keep it rolled tightly (Fig. 4-6).
image The rolled mesh is placed into the abdominal cavity through the 12-mm Hasson trocar; this will avoid mesh contamination from the skin.

image Mesh Fixation

image Once the mesh is inside the abdominal cavity, the two transfascial sutures at the sides of the mesh are pulled through the abdominal wall with the suture passer. This will bring the rolled mesh adherent to the abdominal wall, centering it over the defect with the mesh split toward the colostomy side (Fig. 4-7).
image Care must be taken that the rough surface faces the anterior abdominal wall and the smooth surface faces the viscera.
image The transabdominal sutures are tied. The Vicryl stay suture is cut, and the upper half of the mesh is unfolded (Fig. 4-8).
image By using a suture passer, the superior suture is pulled through the abdominal wall.
image Next, 5-mm hernia tacks are placed circumferentially, 1 cm from the edge of the mesh and 1 to 2 cm apart.
image The same procedure is repeated on the other half of the mesh (Fig. 4-9), cutting the Vicryl stay suture and spreading each part of the lower portion of the mesh individually. The mesh portions are fixed using transabdominal sutures and 5-mm hernia tacks.
image After the mesh is secured properly to the abdominal wall, the gaps between the colostomy and the cruciate defect in the mesh are closed with interrupted 2-0 nonabsorbable sutures securing the mesh to the seromuscular layer of the colostomy loop.
image This will form a collar around the colostomy, eliminating potential spaces for future recurrence.
image Additional transfascial sutures are placed circumferentially at 5-cm intervals to augment long-term stability.
image At the completion of the procedure, the mesh covers the entire hernia defect with 5 cm of overlap while the mesh defect hosts the colostomy loop without restriction (Fig. 4-10).
image

Figure 4-7

image

Figure 4-8

image

Figure 4-9

image

Figure 4-10

image 2 Laparoscopic Sugarbaker Technique (Fig. 4-11)

image The laparoscopic Sugarbaker technique involves placing a flat sheet of mesh on the abdominal wall and lateralizing the stoma’s loop of bowel. In order to perform this procedure, the bowel must have sufficient mobilization to allow it to be displaced laterally without excessive kinking. Occasionally, ileal conduit hernias cannot be lateralized because of the posterior fixation of the ureters.
image Once the defect is measured, an appropriately sized piece of mesh is designed to provide at least 5 cm of overlap.
image We typically suture the bowel to the lateral abdominal wall before bringing in the mesh. This allows the surgeon to see the angle of the bowel before being obscured by the prosthesis. Additionally it confirms that there is not too much tension on the bowel as it makes this angle and avoids the mesh acting as a sling on the bowel wall that is not secured to the abdominal wall.
image Placing the four cardinal transfascial sutures at each corner of the mesh aids in mesh positioning (see Fig. 4-11).
image The mesh is brought into the abdominal cavity through a trocar and unrolled.
image The inferior lateral suture is retrieved first, after 5 cm of overlap is measured. Given the typical lower lateral location of most stomas on the abdominal wall, it is important to retrieve this suture first, since you will often be limited by the major neurovascular structures of the pelvis.
image The superior lateral suture is subsequently retrieved. These sutures are then tightened on the abdominal wall. The surgeon can then see over the mesh and confirm that the bowel is not being too acutely angled as it exits the mesh.
image The remaining two sutures are then stretched out across the abdominal wall and secured.
image A tacking device is then used to secure the mesh to the anterior abdominal wall every 1 cm. When placing tacks next to the stoma site, great care must be used to avoid injuring or obstructing the lumen. There is no exact measurement to allow the surgeon to confirm appropriate mesh and bowel placement, and great care should be used. Because the mesh is placed during full insufflation, it is likely that as the abdomen is desufflated the mesh will loosen a bit.
image

Figure 4-11

4 Postoperative Care

image Use appropriate stoma care.
image Patients are allowed a liquid diet that is advanced as tolerated, although some degree of postoperative ileus may follow, depending on the operative trauma.
image There are no restrictions of activity.
image Abdominal binders aid in the management of postoperative pain and in the preventing of seromas.

5 Pearls/Pitfalls

image When dealing with parastomal hernias, we need to repair the hernia while maintaining the defect in the abdominal wall for the colostomy loop to pass without obstruction.
image Scroll technique facilitates intracorporeal mesh manipulation, maintains precise orientation of the mesh in relation to the hernia defect, and allows secure fixation of the mesh to the anterior abdominal wall.
image The rolled mesh is placed through the 12-mm Hasson trocar into the abdominal cavity; this will avoid mesh contamination from the skin.
image The fundamental components of a sound hernia repair of wide mesh overlap of the defect and transabdominal sutures are used.
image Full-thickness nonabsorbable sutures are crucial for long-term stability of the mesh to the abdominal wall while the 5-mm tacks close the gaps between the abdominal wall and the mesh, thereby preventing incarceration of a loop of bowel between the mesh and the abdominal wall.
image The laparoscopic approach visualizes the entire abdominal wall, thus detecting any impalpable hernia defect that also may be repaired at the same time.
image Large midline defects in addition to parastomal hernias can be very challenging to simultaneously repair, and occasionally, an open approach or the use of two meshes laparoscopically is warranted.
image Suture closure of the hernia defect and reinforcement with the mesh is an optional maneuver that adds security to the mesh repair. However, this may create a tension repair that may necessitate a concomitant component separation.
image These are challenging hernias to repair in a challenging patient population, and all techniques have a potential risk for complication and recurrence, mandating appropriate preoperative counseling.

Selected References

Berger D., Bientzle M. Laparoscopic repair of parastomal hernias: a single surgeon’s experience in 66 patients. Dis Colon Rectum. 2007 Oct;50(10):1668-1673.

Craft R.O., Huguet K.L., McLemore E.C., Harold K.L. Laparoscopic parastomal hernia repair. Hernia. 2008 Apr;12(2):137-140.

Hansson B.M., Bleichrodt R.P., de Hingh I.H. Laparoscopic parastomal hernia repair using a keyhole technique results in a high recurrence rate. Surg Endosc. 2009 Jul;23(7):1456-1459.

Muysoms E.E., Hauters P.J., Van Nieuwenhove Y., Huten N., Claeys D.A. Laparoscopic repair of parastomal hernias: a multi-centre retrospective review and shift in technique. Acta Chir Belg. 2008 Jul-Aug;108(4):400-404.

Muysoms F. Laparoscopic repair of parastomal hernias with a modified Sugarbaker technique. Acta Chir Belg. 2007 Jul-Aug;107(4):476-480.

Saber A.A., Rao A.J., Rao C.A., Elgamal M.H. Simplified laparoscopic parastomal hernia repair: the scroll technique. Am J Surg. 2008 Sep;196(3):16-18.

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