Hernia (2005) 9: 140–144 DOI 10.1007/s10029-004-0295-5
O R I GI N A L A R T IC L E
K. A. LeBlanc Æ D. E. Bellanger Æ J. M. Whitaker M. G. Hausmann
Laparoscopic parastomal hernia repair
Received: 11 October 2004 / Accepted: 4 November 2004 / Published online: 16 December 2004 Springer-Verlag 2004
Abstract Repair of parastomal represents a significant challenge for the hernia surgeon. Repair of these hernias is indicated because of an ill-fitting appliance, cosmetic deformity, inability to maintain proper hygiene and complications from the hernia itself such as incarceration or strangulation. Recent reports in the literature have shown that primary fascial repair can occur in 46% of patients and relocation of the stoma is associated with a 40% recurrence rate. For this reason, the use of polypropylene mesh has been applied to this repair. The recurrence rate with this open technique will still incur a failure rate of 20–29%. Additionally there are other complications such as obstruction, fistulization or mesh erosion with this biomaterial. The laparoscopic approach to this hernia may offer a new choice for this difficult problem. We have used ePTFE to repair 12 parastomal hernias with three different approaches. There have been eight colostomy, two ileostomy and two urostomy hernias. Follow-up ranges from 3–39 months (average 20 months). There has been one recurrence that required two repairs (8%). Other complications included enterotomy (one patient), ileus (one), seroma (one), and death from postoperative aspiration (one). The laparoscopic repair of parastomal hernias appears to be a promising technique for this complex dilemma.
Presented at the meeting of the American Hernia Society, Orlando, FL, February 2004 K. A. LeBlanc (&) Æ D. E. Bellanger Æ J. M. Whitaker M. G. Hausmann Minimally Invasive Surgery Institute, Inc., 7777 Hennessy Blvd., Suite 507, Baton Rouge, LA 70808, USA E-mail:
[email protected] Tel.: +1-225-7695656 Fax: +1-225-7666996 K. A. LeBlanc Louisiana State University School of Medicine, New Orleans, LA, USA
Keywords Hernia Æ Laparoscopy Æ Parastomal
Introduction The repair of parastomal hernias represents a difficult surgical dilemma. The lack of a consistently reliable repair of these defects has plagued surgeons since these were first created. While the overall incidence of all of these hernias is rather difficult to quantify with certainty due to a lack of reporting, it has been reported to occur in as many as 48% of patients with a stoma [1, 2, 3, 4, 5, 6, 7]. The incidence appears to be highest in colostomates and lowest in patients with a urostomy [6, 7]. While some of the literature suggests that location within the rectus sheath will minimize the risk of these hernias, other studies have shown that this is not necessarily accurate [3]. Any stoma can develop a hernia because of the physical alteration of the anatomy of the anterior abdominal wall to allow the egress of the intestinal conduit. The complications of the stoma can be due to either the stoma or the hernia. Stomal complications include difficulty with care of the stoma such as an illfitting appliance, leakage of the contents of the appliance, difficulty with irrigation, or skin excoriation. Hernia complications such as incarceration, strangulation or a significant cosmetic deformity can eventuate in the need for surgical correction. The repair of these fascial defects is complicated due to the need to maintain the defect in the anterior musculature of the abdominal wall. Relocation of the stoma has been touted to be a preferred method to treat this problem. However, this is associated with a recurrence rate of 33–40% [9, 10]. Primary fascial repair is associated with a recurrence rate of 46–76% [9, 10]. Repair that utilizes a polypropylene biomaterial via an open technique has improved these statistics but is associated with a failure rate of 26–29% [11, 12]. Therefore, there is a significant need to improve these results. With the
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success of the laparoscopic repair of incisional hernias, we postulate that the application of these methods to this difficult hernia may offer this advance. We, herein, report our results to date with this evolving technique.
Materials and methods We have performed a prospective evaluation of the patients that we have repaired with the laparoscopic method. This data is current at the time of this writing. None of the patients have been lost to follow-up. All patients are placed in the supine position. It is usually elected to elevate the ipsilateral side of the patient to allow easier access to fixate the prosthesis laterally. The procedure is very similar to that of the traditional laparoscopic incisional hernia repair that we have reported previously [13]. Following introduction of the trocars, adhesiolysis commences and represents the most tedious portion of the procedure. The fascial defect is measured and a DualMesh Plus biomaterial (WL Gore and Associates, Inc., Flagstaff, AZ, USA) is chosen that provides at least 5 cm of overlap of the fascial edges. This is then secured with tacks or constructs and transfascial sutures. We have varied our technique in this series, in an effort to identify a method that is the more superior. We used two overlapping prostheses with a central hole cut in the center or an onlay of the biomaterial on the lateral aspect of the abdominal wall that covers the intestine and the hernia defect [14]. There are two different repairs that were performed on these patients. The two-patch technique was identical except for the choice of biomaterials, either two DualMesh patches or a single Mycromesh with a DualMesh patch placed over this one (Figs. 1 and 2). The first patch is 15·19 cm in size and the second 18·24 cm in size. The second is larger to allow complete coverage of the first patch so that collagen in-growth will also occur into the second biomaterial. The central hole that is
Fig. 1 Initial MycroMesh Plus patch biomaterial with the initial three sutures in place
Fig. 2 Second biomaterial. This is DualMesh Plus with the similarly placed sutures
created in this method has a slit placed to allow the prosthesis to be placed around the intestine. This patch is positioned around the intestine and the sutures are pulled through the abdominal wall with a suture-passing instrument. The edges of this patch are further secured with metal fixation devices such as the Salute constructs (Onux Medical, Hampton, NH). A second prosthesis is placed over this one with its slit placed in a position opposite the slit of the initial patch (Fig. 3). This is utilized to provide coverage of the slit in the initial patch to prevent herniation of bowel through that keyhole. Additional fixation is secured with the placement of constructs and transfascial sutures. The exiting intestine will be sutured to the edge of the hole in the prosthesis to provide immediate fixation of that organ to the biomaterial (Fig. 4).
Fig. 3 The MycroMesh Plus is covered by the DualMesh Plus biomaterial. The colon is seen in the center of the figure
142 Table 1 Parastomal hernioplasty experience Type of repair
Hernia type (number) Complications (number)
Two DM+
Paracolostomy (2)
Para-ileostomy (1) Onlay of DM+ Paracolostomy (4) Paraileostomy (1) Para-urostomy (2) MM & DM+ Paracolostomy (2) Subtotal Paracolostomy (8) Para-ileostomy (2) Para-urostomy (2)
Total
Parastomal hernia repairs: 12
Seroma (1) recurrence of para-ileostomy hernia Ileus (1) Enterotomy (1) Obstruction (1) Death (1) Ileus (1) Seroma (1) Enterotomy (1) Obstruction (1) Recurrence (1) Death (1) Recurrence: 8% Miscellaneous: 25% Mortality: 8%
Fig. 4 Completed repair. The enlarged keyhole is evident near the colon. This will be closed by placing a suture at that site that includes the serosal edge of the colon
DM+ DualMesh Plus, MM MycroMesh
The second repair mimics that of the open repair that was described by Sugarbaker [15]. In this method, the intestine is lateralized along the abdominal wall by sutures. Usually a 15·19 cm DualMesh Plus prosthesis is then placed to cover the bowel and the hernia defect. The intestine must tract along the side of the abdomen to exit through the stoma. There is no defect created in the DualMesh Plus biomaterial. It, like the other method, is secured with transfascial sutures and metal fixation devices (Fig. 5). The results of these methods are shown in Table 1. The age range of these patients was 42–89 years. The average length of follow-up is 20 months (range 3– 39 months). A total of 12 repairs have been completed, seven with the onlay technique and five with the twopatch technique. Intra-operative complication occurred in one patient. An inadvertent enterotomy occurred as the bowel adhesions were lysed from a prior polypro-
pylene repair of the prior hernia. This was laparoscopically closed and the hernia repair was not performed. The patient was returned to the operating theatre in 4 days and underwent a successful repair of the urostomy hernia. Ileus and seroma occurred in one patient each. These are quite common after any laparoscopic incisional hernia repair so that the designation of a complication might be questioned. Nevertheless, these are listed. In neither case did these require any significant intervention. One patient developed a postoperative colonic obstruction. She had undergone a prior relocation of her left lower quadrant colostomy to the right side. An onlay repair was performed for the recurrent hernia. At reoperation, it was apparent that the resultant angulation of her colon resulted in an intermittent obstruction. This was treated by laparoscopic incision of her patch. Subsequent to that procedure she has maintained normal bowel function. One postoperative death in an elderly man was the result of aspiration and subsequent cardiopulmonary arrest. Another patient died of unrelated causes in the follow-up period. The single recurrence was in a male patient with an ileostomy that was placed for ulcerative colitis. The patient developed a recurrent hernia that involved small intestine that had herniated through the slits in the double patch technique. He underwent a laparoscopic reduction of the hernia contents. The intestine was reduced and sewn to the patch laparoscopically. Unfortunately, this recurred and the stoma was repositioned. It has now recurred at the site of the relocation.
Discussion
Fig. 5 Completed paracolostomy hernia repair. The DualMesh patch is seen covering the exiting colon
Parastomal herniation is problematic to the patient and is a significant challenge to the surgeon. The many different techniques that have been reported attest to the
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inability to identify a single permanent and effective solution. It appears that the treatment of this entity is undergoing the same evolution that was seen for the repair of incisional hernias. Primary fascial repair with nonabsorbable sutures has consistently been shown to have an unacceptable rate of recurrence that is as high as 76% [9, 10, 16, 17]. Relocation of the intestinal stoma is frequently touted as the best method to treat this malady. However, most patients would rather not move the location of their ostomy because of its familiarity and the need to undergo a fairly extensive operation. The failure of this attempt is at least 33–40% [9, 10]. Therefore, these surgical attempts are not considered the appropriate approach by most surgeons unless factors require this choice. The additional placement of a prosthetic mesh in some fashion without the relocation of the stoma does appear to have decreased the rate of recurrence. However, there have been mixed reviews on this approach. Morris-Stiff and Hughes reported a 5-year follow-up of seven patients in whom two pieces of polypropylene mesh were sewn to the intestine by ‘‘fingers’’ that were cut into the biomaterial [11]. A recurrent hernia developed in 29% of these patients. Moreover, serious complications such as obstruction or dense adhesions and mesh-related abscess formation were seen in 57% and 15% of these patients, respectively. Tekkis et al. reported the use of a polypropylene mesh to reinforce the in situ repair of fascial repair in five cases and reviewed the literature of other prosthetic repairs of parastomal hernias [18]. No recurrences were seen in their patients after a short-term follow-up of less than 2 years. In their review of the literature of stomal repairs that included a mesh of some type, a recurrence rate of 8.3% was cumulatively seen in 72 patients. This is less than others have reported. Certainly one could make the argument that all of these series had few patients and that they were reported to detail favorable results and that unfavorable results are not generally reported. Others, however, have recently reported 0–20% rates of recurrence [19, 20]. Steele et al. reported on 58 patients that were repaired with polpropylene mesh over a 4-year period, with a mean follow-up of 50.6 months [12]. There was an alarming rate of complications that were related to the mesh in 36% of these individuals. These were recurrence (26%), bowel obstruction requiring surgery (9%), prolapse (3%), wound infection (3%), fistula (3%), and mesh erosion (2%). While they concluded that the use of polypropylene was safe and effective, others, such as the authors would not agree. However, the recurrence rate still represents an improvement to that of primary fascial repair or relocation. The laparoscopic repair of parastomal hernias is in evolution. It is hoped that the diminution of the recurrence and complication rates that have been seen with the minimally invasive approach of incisional hernias will be extended to these very challenging hernias. There are few studies that have been reported with this
technique. The largest series has been that of Berger, which includes 15 patients [4]. He uses an onlay technique that uses fixation with transfascial sutures and tacks. Unless the patch is greater than 20 cm, he does not use any more than four sutures. He, too, prefers an overlap of 5 cm for this procedure. In the immediate postoperative period, one patient developed a hematoma and one patient required re-operation because of incarceration of small bowel between the patch and the abdominal wall (due to a ‘‘dislocated tack’’). Three of these patients (20%) developed a recurrent hernia between 2 and 4 months. One could certainly postulate that the method of fixation may be inadequate because of the relatively few transfascial sutures that were used in this repair. We believe that it is critical that these sutures are used at not more than 5 cm apart along the entire periphery of the patch unless there is a structure such as the iliac bone that prohibits its placement [21]. In this instance, the patch should be secured with many more of the metal fixation devices than would be the usual recommendation. Some surgeons have trephined the bone to place sutures to ensure fixation, however. There have been single case reports that have placed polypropylene mesh circumferentially around the exiting intestine to repair the defect. Pekmezci et al. used a polypropylene mesh to repair the hernia [22]. They chose to use the biomaterial because ‘‘it was cheaper and easier to manipulate’’ while acknowledging the fact that it is associated with enteric erosion, erosion and extrusion. Dunet et al. and Deol et al. used a similar type of technique for ileal conduits but used expanded polytetrafluoroethylene as the prosthesis [23, 24]. None of these patients have experienced a complication but all of the follow-up was very short. Our series is one of the largest and with significantly longer follow-up than most others. Based upon our prior experience with DualMesh Plus with incisional hernia repair and longer-term evaluation postoperatively, we believe that this is the best biomaterial that is available currently for this procedure. It is effective and has a low rate of postoperative adhesion formation [25]. Based on our early use of the two-patch technique with the central hole and slits, we think that this procedure should not be used for an ileal stomal hernia. The small caliber of this intestine may allow it to invaginate into the hole of the patch, thereby creating a recurrence, as we experienced. The onlay method appears to require slightly less operative time than the two-patch technique. It also avoids the concern of herniation of the contents of the abdomen through the slit in the product. We are continuing to follow all of these patients to assess the long-term outcome. Currently, we feel that the single-patch technique as an onlay repair might be the better alternative. It is simpler to perform and mimics the successful open repair of Sugarbaker [15]. The complication rate of 25% is somewhat high but these were mostly minor and not associated with any longterm adverse consequences. We continue to closely
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monitor these patients to determine the true recurrence rate. This will require a minimum of 3 years of followup. Until then, we do not see any need to modify this approach to these hernias.
Conclusion The laparoscopic repair of parastomal hernias appears to be a successful technique that is evolving. The onlay or two-patch technique appears to be successful in the short term. However, the two-patch method is not recommended for ileostomy hernias. Longer follow-up of these patients will be necessary to ascertain its efficacy.
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