Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure.

INTRODUCTION: Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel. PATIENTS AND METHODS: Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects.
RESULTS: Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma.
CONCLUSION: Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.

INTRODUCTION

A parastomal hernia is one of the most common long-term complications after abdominal ostomy. The overall incidence of parastomal hernia is unknown, but it is estimated to be over 30% by 12 months, 40% by 2 years and 50% or higher at longer duration of follow-up.[12] Any stoma can develop a hernia due to the artificial defect created in the abdominal wall; however, end colostomy is reported to be associated with a higher incidence of parastomal hernia, compared to loop colostomy and loop ileostomy.[2] Patients commonly present with pain, heaviness or for cosmetic reasons. They may also present with various complications which can be due to either the stoma as ill-fitting appliance, leakage of the contents of the appliance, difficulty with irrigation, or skin excoriation or with complications of the hernia such as incarceration or strangulation which may require an emergency repair.

Surgery is the only form of treatment for parastomal hernia. Conventional surgery for parastomal hernia entails three most common surgical approaches which are primary fascial repair, stoma relocation and repair with mesh. There is no high-quality evidence of high risk of recurrence following stoma relocation (33%–40%) and primary suture repair (46%–76%).[34]

Mesh reinforcement currently has become a widely accepted procedure and it may be performed both open or laparoscopically. Minimal Access surgery has proven advantages of less pain, early return to daily activity and better cosmetic outcome in addition to repair of parastomal hernia with prosthesis at the same site.[5]

Composite mesh now enjoys widespread popularity for intraperitoneal onlay repair of ventral hernia, and the same concept can be applied here as well. For the intraperitoneal techniques, surgeons generally utilise one of two major methods such as the keyhole technique or the modification of ‘Sugarbaker’ procedure. The Sugarbaker technique has a significantly lower recurrence rate than the keyhole method.[56] Despite favourable efficacy, safety and long-term follow-up assessments of laparoscopic parastomal repair, there are reports of mesh infection, obstruction, fistulisation or mesh erosion.[7] In this article, we report our novel modification of composite mesh placement in Sugarbaker procedure to minimise mesh erosions into the stomal loop of bowel.

PATIENTS AND METHODS

A retrospective analysis of 14 consecutive patients who underwent laparoscopic intraperitoneal mesh Sugarbaker repair for parastomal hernia was made. Institutional Ethics Committee permission was sought. The inclusion criteria for this study were patients having a permanent stoma who were symptomatic and presented with a parastomal bulge or abdominal distention or pain; who had problems with stoma care and those who wanted correction of the cosmetic disfigurement of their abdomen. A pre-operative contrast-enhanced computerised tomography (CT) scan of the abdomen performed for all patients did not show any recurrence of primary pathology for which stoma was created and the abdominal musculature and defects were studied. Details of patients including intraoperative findings, procedure details and post-operative course were recorded from the hospital records.

Pre-operative preparation

All patients had received mechanical bowel preparation 24 hours before surgery. Perioperative antibiotics were administered as per the institutional protocol, and all patients were provided with perioperative lower limb compression stockings.

Anaesthesia

All cases were performed under general anaesthesia with endotracheal intubation. Pre-operative epidural analgesia catheter insertion was done in all patients that remained in situ until the third post-operative day (POD).

Surgical position, preparation of operative field and trocar placement

The patient was positioned in supine and Trendelenburg position (15°). The abdomen of the patient was painted twice with povidone-iodine 7.5% (w/v) surgical scrub from nipple to the knee. After 3 min, the same area was painted with surgical spirit (ethanol 70% v/v) twice. The peristomal area was cleaned with 10% (w/v) povidone-iodine solution twice, and a gauze piece soaked in that solution was placed over the stoma and isolated from the operative field using adhesive transparent film dressing.

The operating surgeon and the camera surgeon stood on the right side of the patient, and the surgical assistant stood on the left side because the colostomy stoma is usually located in the lower left quadrant of the abdomen. The monitor was positioned towards the left foot end.

Veress needle was used to create pneumoperitoneum through Palmer's point. A 10-mm trocar was placed using an open technique below the right costal margin in mid-clavicular line. Triangulation was attained to have better ergonomics for adhesiolysis and suturing of the defect. Under vision, another 10-mm trocar was placed into the right anterior axillary line above the anterior superior iliac spine (usually approximately 10 cm below the first trocar) and a 5-mm trocar was placed in the midpoint between the umbilicus and the xiphoid process to serve as the operating port.

Surgical procedure

Adhesiolysis was carried out with sharp dissection and judicious use of energy to identify the defect and also to detect any occult hernias in the previous scar. Contents of hernia were carefully reduced to avoid any injury and disconnection of the stomal loop. The hernia sac was partially excised to prevent seroma, and the defect size was measured.

The defect was repaired using intracorporeal continuous shoelace technique with a single non-absorbable suture (No. 1 monofilament nylon [polyamide] Loop) after lateralising the stoma. The suture was begun at the stomal end taking good full-thickness bites of the rectus sheath 1 cm away from defect edge and 1 cm apart. The nylon suture was passed to and fro for the whole length of the hernia defect in a manner of shoelace tightening a boot [Figure 1]. The end sutures were then pulled to approximate the defect with a lowered abdominal pressure to 8 mmHg while keeping a finger of assistant inside the stoma to avoid narrowing of the stoma. The knot of the suture was placed in subcutaneous tissue.

Figure 1

Primary suture repair of the hernia defect with the shoelace technique

The repair was then reinforced with a composite mesh. Most hernia defects have the largest dimension in the range of 4.5 cm–6 cm in diameter. The mesh should be at least 15 cm × 20 cm enough to cover the bowel loops to the stoma. We used a larger composite mesh measuring 20 cm × 25 cm (Parietex™ Composite Mesh | Medtronic) so that the ventral surface of the mesh is folded to face the stomal loop until it exits, and the folded end of the mesh is pulled until lateral abdominal wall allowing a good 5-cm cover of mesh to the defect [Figure 2]. The mesh was used vertically for 20 cm and transversely for 25 cm so that we could have a minimum 9-cm infolding of the mesh and still have at least 5-cm overlap of the mesh from all sides [Figure 3a].

Figure 2

As the mesh is unrolled, ventral surface of mesh is kept folded to face the stomal loop

Figure 3

(a) Schematic diagram in sagittal plane showing the infolding of the mesh before fixation. The size of the folded part (red) can vary depending on the size of the defect. (b) Schematic representation of how mesh is placed with ventral surface facing the stomal loop before fixation

Just like in the Sugarbaker procedure, the bowel loop was lateralised to the anterior and lateral abdominal wall, and enough room between the mesh edge and the abdominal wall was left to allow the bowel loop to pass through.[8] As the mesh is inserted and unrolled, the lateral edge of the mesh on lateral side was folded with ventral side of the folded mesh facing the stomal loop so that the parietal surface of the mesh does not come in contact with loop [Figure 3b]. The folded edge of the mesh was placed laterally onto the lateral abdominal wall and the mesh was fixed with absorbable tackers and intracorporeal absorbable suture, with fixation around the defect and the stoma first and then at periphery [Figure 4]. This allowed only ventral aspect of the mesh to be in contact with the stomal loop. At the end of the procedure, haemostasis is confirmed, and pneumoperitoneum evacuated and port site fascia repaired.

Figure 4

End result of mesh fixation. The stomal loop is lateralised like in Sugarbaker technique

Post-operative care

Patients were started on orals on next day, and early ambulation was encouraged. All patients received intravenous antibiotics for 5 days and were evaluated for any redness, swelling, subacute obstruction and recurrence of the hernia.

RESULTS

A total of 14 patients underwent laparoscopic parastomal hernia repair out of which there were eight males and six females with age ranging from 42 to 78. One patient had an end ileostomy who underwent total colectomy for ulcerative colitis, and one patient had a urinary ileal conduit following surgery for carcinoma urinary bladder, rest had sigmoid stoma after abdominoperineal resection done for carcinoma rectum. The most common presenting symptoms were pain at the hernia site associated with bulge in stoma area. Three patients had problems with stoma bag application and required straps for holding of the bag. Nearly all of them had frequent appliance leakage and resorted to change of bag on alternate days. All cases of hernia had small bowel as contents. Average defect size was 4.5 cm × 6 cm (CCx TRA) and average operative time was 125 min. We recorded no conversion to open procedure. Pain assessed on VAS score was higher in the first 12 h [Table 1].

Table 1

Pain assessment with average visual analogue scale score in relation to the size of defect

Defect size - largest dimension (cm)	Number of patients	VAS score at 6 h	VAS score at 12 h	VAS score at 24 h	VAS score at 48 h
4.5-5 0.5	8	6	5	3	2
5.5-6.5	6	7	5	2	2

VAS: Visual analogue scale

Orals were started on the first POD for most of the cases (eleven patients). Stoma started functioning on POD 3 for colostomies and POD 1 for ileostomies. Only one patient had a prolonged ileus and stoma function was seen on POD 5. All patients were mobilised early and given chest physiotherapy. All our patients were serially followed up at 4 weeks, 3 months, 6 months and up to 1 year. Longest follow-up of 7 years and the shortest of 15 months did not reveal any complications such as seroma formation, stomal necrosis, mesh infection and erosions or hernia recurrence.

DISCUSSION

Parastomal hernia occurs in nearly 50% of all stomas.[12] Their repair has been a constant challenge to surgeons worldwide. Hence, many techniques and innovations published in the literature so far attest to the fact that no single repair is permanent and effective. Apart from the cosmetic disfigurement and complications of obstruction or strangulation, those patients who are troubled by ill-fitting appliance or leakage are the ones who really warrant repair to improve their quality of life. The treatment of parastomal hernia has evolved extensively. In the modern era, primary suture repair is unacceptable due to its high recurrence rate. Stoma relocation seems a good option, but it predisposes to three potential hernias– at the midline, at the previous stoma site and a parastomal hernia at the new site. Cheung et al. have stated incidence of incisional hernia in 52% of patients who underwent stoma relocation.[4] Both open and laparoscopic techniques have been described and laparoscopic technique has been increasingly preferred over the past two decades after positive results from laparoscopic repair of ventral hernias. The laparoscopic approach is appealing for many reasons. There is no need to relocate stoma. There is no disturbance of the stoma, the incisions are small and, therefore, wound infections and wound-related complications should be low. In addition, the minimal access approach is associated with the benefits of less post-operative pain, a lower analgesic requirement, reduced morbidity, a shorter hospital stay and an earlier return to full activity. As a mesh is used, the laparoscopic repair should replicate the relatively good results regarding recurrence rate that has been reported with open mesh repair. In addition, the technical principles of the surgery including the laparoscopic adhesiolysis, dissection and mesh placement are essentially the same as those familiar from laparoscopic incisional hernia/ventral hernia repair, a procedure that many surgeons are capable of executing comfortably.

Meshes for parastomal hernia repair were introduced almost 30 years ago, but there have been persistent concerns related to the mesh being in proximity to the bowel, putting it at risk for adhesive, erosive and eventually infectious complications. Morris-Stiff and Hughes and Steele et al., have reported in their studies about polypropylene meshes causing dense adhesions between the mesh and the adjacent organs.[910] Its sharp edges and the formation of sharp folds due to shrinkage of the mesh can even cause erosion of the bowel wall leading to the need for removal of mesh.[11] Their usage for parastomal repair is, therefore, discouraged currently. Expanded polytetrafluoroethylene (e-PTFE) mesh is another alternative synthetic mesh which is soft and reported to form fewer adhesions and less likely to erode into the stomal bowel loop.[5] However, this mesh also lost acceptability due to a higher risk of re-herniation and susceptibility to infection and if infected should be removed. These drawbacks of e-PTFE mesh are attributed to its hydrophobicity and microporous composition that does not allow tissue ingrowth into the prosthesis.[1213] With recent advances, biologic grafts have been used for parastomal hernia repair as an alternative, but they are very expensive, and results are similar to synthetic mesh repair.[14]

Despite the abundance of meshes currently available, the ‘ideal mesh’ that should combine rapid ingrowth in the abdominal wall, offer high resistance to infections, and completely lack adhesion to the intestine is not yet available. Currently, composite meshes are considered most suitable for parastomal hernia repair and were used in the current study. We used composite mesh with modified method of placement with upward folding of the visceral non-adhesive surface at the area where the stomal loop is parietalised. Theoretically, this minimises the risk of mesh eroding into the bowel or causing adhesion and leading to problems of stoma obstruction. Practically also, we recorded no complications of mesh infection, and subsequently, no recurrences were seen. Thus, modified placement of composite mesh is safe and helps in minimising mesh-related early complications of the Sugarbaker technique for parastomal hernias.

CONCLUSION

Laparoscopic parastomal hernia repair with modified placement of composite mesh in Sugarbaker technique may help in reducing mesh-related complications, in turn, decreasing the risks of hernia recurrence in addition to advantages of minimal access surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.