A case report of modified laparoscopic keyhole plus repair for parastomal hernia following ileal conduit.

Parastomal hernia is one of the most common but challenging complication after stoma formation. Modified Sugarbaker technique is the recommended procedure for repair parastomal hernia, however, keyhole repair technique had also been used in certain instances. In cases of parastomal hernia following ileal conduit procedure, the Sugarbaker technique is been described, although with associated theoretical risk of conduit failure. We are reporting a case of post-radical cystectomy with ileal conduit presented with symptomatic large parastomal hernia. Laparoscopic modified keyhole plus repair has been done successfully in this patient with no recurrence in 2 years of follow-up. The purpose of our case report is to describe our novel modification of the laparoscopic keyhole technique which can be a feasible and acceptable alternative surgical method in these types of patients.

INTRODUCTION

Parastomal hernia is one of the most common causes of morbidity following permanent stoma creation, which has been reported to occur in nearly half of patients within 2 years.[1] Various open and laparoscopic techniques have been described in literature to address this problem, however, modified Sugarbaker technique has wider acceptance and has shown lowest recurrence rate.[2] Its adaptation in minimally invasive approach too, is well reported with good outcomes. Especially, in cases of parastomal hernia with ileal conduit, the applicability of this technique is quite challenging as the complex structure comprising conduit along with implanted ureters poses a theoretical risk of compression by mesh, leading to conduit failure. To the best of our knowledge, there is no consensus or guidelines particularly addressing a parastomal hernia following an ileal conduit surgery.

Another option available is the technique of key-hole repair, albeit reported with higher recurrence rate in literature.[3] Hereby, we are reporting our technique of laparoscopic modified keyhole plus repair in a case of parastomal hernia following ileal conduit showing good outcome without recurrence in 2 years of follow-up.

CASE REPORT

A 59-year-old man reported with partially reducible swelling around ileal conduit for last 8 months, which was associated with intermittent dragging pain. He was diagnosed with adenocarcinoma of urinary bladder for which he underwent radical cystectomy with ileal conduit followed by adjuvant chemotherapy, completed 3 years back. He was on regular follow-up without any evidence of recurrent disease. He had no other comorbid conditions. On examination, he was found to have large parastomal hernia around ileal conduit which was partially reducible having small bowel and omentum as contents [Figure 1]. After thorough clinical and radiological evaluation, he underwent laparoscopic keyhole plus mesh repair (the surgical technique is described below) with an uneventful post-operative recovery.

Figure 1

Pre-operative image of large parastomal hernia

Surgical technique

Team setup

The patient is kept in supine position. The entire team stands on left side of patient as most conduits are made on the right side. The camera surgeon stands near cranial end, while the scrub nurse stands near caudal end of the patient towards left side of surgeon. The monitor is placed on the right side of the patient, directly opposite to the surgeon. A Foley's catheter is placed in the stoma with balloon inflated as it helps to differentiate between the loop of small bowel forming the stoma and intestinal contents of the hernia.

Port placement

Total four ports are used – one 10 mm camera port in the left anterior axillary line at the level of umbilicus, two 5 mm ports over the left midclavicular line in left hypochondrium and lumbar region 20 cm apart as right hand and left hand working ports, respectively. Another 5 mm port is placed for retraction in the right midclavicular line 2 cm beneath the costal margin.

Procedure

The principles of surgery are, reduction of the contents, removal of sac, narrowing of the parastomal defect and mesh reinforcement. Pneumoperitoneum is established with Veress needle, ports made as described. Lysis of the extensive adhesions that are usually present has been done using both blunt and sharp dissection until the defect is delineated completely [Figure 2a]. The contents are dissected and reduced and the defect is closed laterally with no. 1 prolene [Figure 2b] in continuous intracorporeal fashion, taking care not to constrict the stoma (usually checked by passing the tip of the instrument between the stoma and the defect). A composite mesh is placed in an intraperitoneal onlay manner [Figure 2c], laterally extending beyond the stoma site, with the absorbable collagen layer towards the intestines and the nonabsorbable polyester layer towards the parietal wall (Parietex, Covidien, Trevoux, France). Few seromuscular stitches are taken from the conduit to the parietal wall, to avoid a dragging effect. The mesh is then fixed using a combination of trans-fascial sutures and tackers (Strap 25R, J and J, Ethicon, NJ, USA), like in a conventional laparoscopic ventral hernia repair. Pneumoperitoneum was deflated, ports removed and skin closed with subcuticular stitches with absorbable suture material. The operative procedure took 108 min. In the post-operative period, oral liquids were started within 24 h and the patient was discharged on 3rd post-operative day. He was followed up for 2 years with no recurrence.

Figure 2

(a) Intraoperative image showing large defect with herniation of content. (b) Intreoperative image after closer of defect with prolene 1-0. (c) Intraoperative image after mesh fixation to peritel wall

DISCUSSION

Parastomal hernia represents a relatively uncommon but challenging scenario post-stoma creation, associated with high recurrence rates in the setting of multiple prior operations.[23] Most parastomal hernias can be managed conservatively if asymptomatic,[4] however, 30% to 70% usually require surgical intervention in patients presenting with symptoms such as pain, prolapse, poor fitting of appliances and obstruction.[45] Over the last few decades, various techniques have been described for parastomal hernia repair including laparoscopic approach, with added benefits of better cosmesis, less blood loss, early post-operative recovery and less incidence of recurrence in comparison to open approach.[3] The published studies in literature describes two most commonly performed laparoscopic repairs for parastomal hernia with good results as the Sugarbaker technique and the key-hole technique.[34] The Sugarbaker technique is widely used nowadays (including our centre) because of its lower incidence of recurrence compared to the keyhole technique for repair of parastomal hernia. However, in cases of parastomal hernia with ileal conduit, the Sugarbaker technique is challenging and carries a risk of conduit failure caused by mesh compression.[15]

Although the keyhole repair technique had been described in literature to be associated with high recurrence rate,[4] our technical modifications like removal of sac, closing of defect in intracorporeal fashion followed by reinforcement with composite mesh could have reduced the risk of recurrence. We feel this modification is a safe, effective and feasible option with better cosmetic results having other advantages of minimal access surgery. To the best of our knowledge, these modifications were not described elsewhere in the literature so far.[146]

CONCLUSION

The laparoscopic keyhole plus repair technique is a safe, feasible and effective option for parastomal hernia repair complicating an ileal conduit creation with good cosmetic and functional outcome and an acceptable recurrence rate. This technique is a complex procedure that demands good skill and patience for optimal results. The purpose of our case report is to describe our modification of laparoscopic mesh-keyhole technique which can be an alternative surgical method in these groups of patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.