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

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)

Magnitude of the problem Between 87000 and 135000 intestinal stomas (ileostomy and colostomy) are created each year Approximately 1/2 will be permanent stomas 30-50% of these (20-35000) will develop parastomal hernias wich will require surgical repair

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

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

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

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

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

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

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

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 v185 436-440

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

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

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

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): 685-695

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

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

adhesiolysis

sugarbaker (exiting side of mesh)

sugarbaker Fascial defect Stoma bowel exiting side

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 (240-780) 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

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

KEYHOLE tecnique

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. 2009 July

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

prevention of parastomal hernias

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

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

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%)

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

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

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

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

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

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