1. Parastomal Hernia: what to do?
LAPAROCELI: Laparoscopy Live Surgery
Parastomal Hernia: what to do?
Ospedale di portogruaro
U.o.C. chirurgia generale
francesco fidanza

2. parastomal hernia
“Some degree of herniation around a colostomy is so common that this complication may be regarded as inevitable” ( Goligher)
“It doesn’t matter if God Himself made your ostomy. If you have it long enough you have a 100% risk of a parastomal hernia” (J Byron Galthright)

3. Magnitude of the problem
Between and intestinal stomas (ileostomy and colostomy) are created each year
Approximately 1/2 will be permanent stomas
30-50% of these ( ) will develop parastomal hernias wich will require surgical repair

4. Parastomal hernia risk factors
Patient factors
Age
Intra abdominal pressure factors
Obesity
Emphysema

5. Parastomal hernia risk factors
Wound healing factors
Infection
Steroids / Immune modulators
Genetics (collagen deficiency)

6. Parastomal hernia risk factors
Mistakes in surgical technique
Site outside of rectus sheath
Stoma defect created too large

7. Symptoms of parastomal hernia
Protrusion of stoma beyond abdominal wall
Prolapse of stoma
Enlargement of stoma
Severe parastomal skin irritation
Severe parastomal pain
Incarceration or strangulation

8. hernia confirmedd symptoms absolute indication for surgery mayor
minor
symptoms
contraindication
for
surgery
conservative
care
local repair
local repair with mesh
re-location
symptoms

9. treatment
The best treatment for a parastomal hernia is, of course, reversal of the ostomy (when it is possible) Carne PWG, Robertson GM, Frittelle FA Parastomal hernia Br J Surg 2009
The open approaches to repair of parastomal hernias include primary fascial repair, repair with mesh, and stoma relocation. Primary fascial repair, although technically simple, carries a recurrence rate of up to 50%. Allen-Marsh TG, Thomson JP. Surgical treatment of colostomy complications Br J Surg 1998

10. non-mesh technique ‘Takedown’ Primary suture repair is unacceptable
Stoma “resite” results in 3 potential hernias
Midline incision
Old stoma site
Parastomal at new site

11. Open onlay Easy to reduce hernia Difficult to lyse adhesions
Large peri-wound cavity
Wound complications
Difficult for Patient to care for ostomy postop
Via Midline
Difficult in obese pts
Can devascularize tissue
Recurrence up to 26%
Steele SR. Am J sunrg 2003 v

12. No recurrences or infections at 30 months
open repair REsulTS
Author
No. of pts
Material
Results
Steele, ’03 58
Polypro mesh
26% recurrence; 9% SBO; 3% prolapse; 3% wound inf.; 3% fistula; 2% mesh erosion
Stelzner, ‘04 20
PTFE
3/20 recurred at 3.5 years
Longman, ‘05 10
Polypro
No recurrences or infections at 30 months

13. surgical laparoscopic techniques
It was not until 1998 when Percheron et Al described the first laparoscopic repair of parastomal hernias as a possible solution to this common problem

14. laparoscopic surgery
The most difficult of any laparoscopic parastomal hernia repair is the safe division of adhesions
Favorable factors for successful laparoscopic approach to bowel surgery
Prior laparoscopic surgery
Fewer than 2 prior surgeries
Milder abdominal distension
Pliable abdominal wall
Lack of mesh
Lack of enterocutaneous fistula

15. laparoscopic surgery
The mesh can be formatted on the basis of either of 2 main principles.
The modified Sugarbaker technique with a nonslit mesh covering the hernia defect with at least a 5-cm overlap with lateralization of the colon/ileum going into the stoma.
The keyhole technique, where a hole is cut out to encircle the stoma with a slit and the mesh covers the hernia around the bowel.
Hanson BM, Slater NJ, Van der Velden AS, et Al. Surgical techniques for parastomal hernia repair: a systematic review of the literature. Ann. Surg. 2012; 255(4):

16. O.R. set-up
K. Harold Operative Tecniques in Gen. Surg. 2007

17. sugarbaker technique
K. Harold Operative Tecniques in Gen. Surg. 2007

18. adhesiolysis

19. sugarbaker (exiting side of mesh)

20. sugarbaker
Fascial defect
Stoma bowel exiting side

21. outcomes lap parastomal hernia repair (sugarbaker technique)
Patient Characteristics (N=21)
Mean age (yr)
66 (36-82)
Mean defect size (cm2)
130 (25-416)
Mean mesh size (cm2)
440 ( )
Mean operative time (mins)
210 (99-326)
Mean L.O.S. (days)
6 (2-14)
Mean follow up (months)
20 (6-36)
Laparoscopic success rate
100%
Recurrences
1 (5%)
Complications
10 (50%)
K. Harold et al. Hernia 2007 Nov

22. KEYHOLE tecnique
K. Harold Operative Tecniques in Gen. Surg. 2007

23. KEYHOLE tecnique

24. outcomes lap parastomal repair
55 patients
Keyhole technique
85% completed laparoscopically
Mean LOS 4 days
6 enterotomies
2 mesh infx
36 mo f/u (12-72mo)
20 recurrences (37%)
Hansson, BM et al., Surg Endosc July

25. keyhole vs. sugarbaker (lap) (literature review)
Repair type
No. pts (60)
O.R. time (min)
LOS
Comp. %
Recur. %
Keyhole 38
242
4.4
20% (0-33%)
27% (0-44%)
Sugarbaker 22
125
3.9
12% (0-25%)
16%(0-19%)
K. Harold et al. Presented American Hernia Society 2006

26. prevention of parastomal hernias

27. Prophylactic mesh
There has been a flurry of interest to reinforce the abdominal wall with a piece of mesh every time a stoma is made. Studies have shown cost-effectiveness in placing a mesh prophylactically in those patients requiring a permanent stoma
Lee L, Saleem A, Landry T, Latimer E, Chaudhury P, Felman LS. Cost effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing permanent colostomy for rectal cancer. J Am Coll Surg 2014

28. prophylactic mesh a study of mayo clinic
I want to show you a study done at Mayo Clinic on prophylactic positioning of a mesh during the packaging of a stoma

29. Results O.R. Time (min) Ave Blood Loss (ml) Length of Stay (days)
Mesh (16)
No Mesh (23)
O.R. Time (min)
275
285
Ave Blood Loss (ml)
375
1000
Length of Stay (days)
10 (5-17)
9.6 (6-25)
F/U (months)
17.5 (3-34)
17.1 (4-36)
Hernia
1 (6%)
7 (31%)

30. results
Eight pts (31 %) with a standard stoma formation developed a hernia
One pt (6 %) with mesh reinforcement develop a hernia
p = .029
pts without hernia
pts with hernia reinforcement
pts without mesh

31. follow up standard stoma formation without mesh
stoma formation with mesh reinforcement

32. Complications Mesh Group
1 patient required post- op transfusion of anemia
No mesh related complications
No Mesh Group
3 patients with ileus
1 patient with CHF
1 patient with pelvic abscess

33. conclusions Lap parastomal hernia repair is feasible
Results appear to be better than open repair
Technique is demanding
Sugarbaker easier / faster than Keyhole
Prevention may be the best answer

34. our best choice In these years we experimented both techniques:
modified Sugarbacker
keyhole technique
BUT THE TECHNIQUE WE PREFER IS

35. THANK YOU VERY MUCH! Ospedale di portogruaro U.o.C. chirurgia generale
francesco fidanza