Acta chir belg, 2007, 107, 476-480

Laparoscopic Repair of Parastomal Hernias with a Modified Sugarbaker Technique

F. Muysoms Department of Surgery, AZ Maria Middelares, Gent, Belgium.

Key words. Laparoscopy ; parastomal hernia ; abdominal wall hernia ; mesh ; hernioplasty. Abstract. Background : With the increasing experience in laparoscopic ventral and incisonal hernia repair this minimal invasive technique has also been used to repair parastomal hernias. Different types of laparoscopic repair have been described. Methods : Laparoscopic repairs can mainly be divided in two groups : keyhole-techniques and Sugarbaker techniques. We reviewed the literature and described our current technique, using a modified Sugarbaker technique in detail. Results : We have used the technique in five patients with good early results, no early recurrences and good functional outcome. Conclusions : Laparoscopic repair of parastomal hernias is a safe and feasible technique. In our experience, laparoscopic parastomal hernia repair with keyhole techniques had a disappointing high recurrence rate. Therefore we changed to a modified Sugarbaker technique with promising early results.

Introduction A parastomal hernia is a frequent pathology in patients with a colostomy or ileostomy (1). Recently it has been shown that the development of parastomal hernias could be prevented by placement of a lightweight mesh in a sublay position at the time of stoma creation (2). A parastomal hernia is often well tolerated and a repair is only needed if symptoms like obstruction, incarceration or difficulty of appliance (colostomy pouch) application. Many different techniques for repair of parastomal hernias have been proposed (1). Open techniques can be divided into : local tissue repair, repair by stoma relocation and repair with mesh. Local tissue repair and stoma relocation have a high rate of recurrence. Moreover stoma relocation caries the risk of incisional hernia at the old stoma site. In an attempt to lower the recurrence rates several types of mesh repairs have been proposed. The position of the mesh varies from intraperitoneal to preperitoneal or fascial onlay. A laparoscopic approach has been proposed to combine the benefits of minimally invasive surgery with the use of mesh. Also in the laparoscopic era, different techniques have been proposed. Laparoscopic repairs can mainly be divided in two groups : keyhole-techniques and Sugarbaker techniques. Several different types of keyhole repairs have been described (3-7). They all have in common that

the parastomal hernia is repaired with an intraperitoneal mesh with a central hole or slit in the mesh to allow the colon or the ileum to pass through the mesh to go to the stoma site. In so-called Sugarbaker or modified Sugarbaker techniques a single uncut piece of mesh is placed as an intraperitoneal onlay patch. In this paper we will describe in detail our current technique for repair of parastomal hernias and give our arguments to prefer a modified Sugarbaker technique over a keyhole technique. Modified Sugarbaker technique for laparoscopic parastomal hernia repair Sugarbaker described in 1980 an open technique for repair of parastomal hernias using an intraperitoneallyplaced polypropelene mesh as an inlay mesh repair (8). No hole was made in the mesh but the bowel going to the stoma was lateralized and covered by the mesh. He reported excellent results in seven patients with no recurrences at 4 years of follow-up (9). STELZNER et al. reported a modified Sugarbaker technique in 20 patients. By laparotomy an intraperitoneal ePTFE mesh, with overlap of the hernia defect of at least 5 cm in all directions was placed (10). With a mean follow up of 3.5 years, they saw three asymptomatic recurrences (15%). Several papers have described laparoscopic adaptations of this successful open Sugarbaker technique (11-14).

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We would like to define the Laparoscopic Modified Sugarbaker technique for parastomal hernia as : a repair by laparoscopic technique of a parastomal hernia by placement of an intact intraperitoneal mesh overlapping the hernia defect and with lateralisation of the bowel going to the stoma. Indications for repair are usually : obstruction, incarceration and difficulties in applying the stoma appliance material. It is common practice not to operate on oligoor asymptomatic patients. Care should be taken not to broaden the indications for repair of these hernias just because there is a new minimally invasive technique that we want to adopt. Not before we have long-term followup data with low recurrence rates and low complication rates, might we justify considering to operate on less symptomatic patients. Preoperatively some laxatives are given. A proper bowel preparation could be considered but is not given in our practice. One single dose of cefazoline is given during induction of anesthesia. Patients are operated under general anesthesia with tracheal intubation. Special attention should be given to patients operated for incarceration and obstruction to avoid aspiration of stomach content resulting in pneumonitis by inhalation. The patient is in the supine position with both arms alongside the body. The arms should be tucked underneath the sides of the patients to allow access to the lateral border of the abdomen where the trocars will be placed. After desinfection, the operative field is draped. Again we emphasize the importance of keeping the operative field broad enough to expose bilaterally the lateral sides of the abdomen. We cover the stoma with a gauze and cover the stoma site and the whole operative field with a plastic drape. Doing this the stoma itself is during the operation never in contact with the operative field. Therefore we think the risk of contamination of the mesh should not be higher than for other laparoscopic incisional hernia repairs not involving a stoma. Positioning of surgeons, trocars and video equipment for a left sided colostomy is given in Fig. 1. Usually a pneumoperitoneum is created with a Verres needle subcostally at the anterior axillary line. We use an intraoperative abdominal pressure of 12 mmHg. When this pressure has been reached a trocar of 10 mm is inserted on the same anterior axillary line halfway between the costal margin and the superior iliac crest. A 30 angeled scope of 10 mm is introduced. The position of the Verres needle is checked and lesions to the bowel or the liver by the puncture are excluded. A second trocar of 10 mm is inserted subcostally. This will be the site of the scope during the operation. Finally a third trocar of 5 mm is placed just above the superior iliac crest. If needed the region where this trocar is to be inserted is released of adhesions. If many intraperitoneal adhesions are suspected an open laparoscopy can be used to create the

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Fig. 1 Positioning of trocars, surgeons and equipment for laparoscopic repair of a parastomal hernia of a left sided colostomy.

pneumoperitoneum as an alternative for the Verres needle technique. Complete adhesiolysis of the anterior abdominal wall is performed, including release of the round ligament of the liver if this is necessary. Care is taken to avoid accidental enterotomy. Indeed adhesiolysis can sometimes be difficult in these patients (15). It is a potentially dangerous step of the operation, certainly if a bowel lesion is missed and only recognised postoperatively. Delayed bowel lesions can result in intraabdominal sepsis and multiorgan failure. Therefore it is recommended to perform the adhesiolysis with a sharp dissection, only cutting under good visibility and with certainty about the structures being cut. We advise to use energy sources like coagulation or electronic scissors only scarcely. We always look for the avascular plane between the adhesions and the abdominal wall. This avascular plane is usually present and can be recognised by moderate traction on the adherent structures. In cases of recurrent hernias after previous mesh repair the avascular plane might not be present and adhesiolysis in these cases can be very difficult or even impossible. The content of the hernial sac is reduced after identifying the colon going to the colostomy and its mesocolon. The peritoneal sac is left in place. To be able to achieve adequate lateralisation of the colon, we recommend freeing all adhesions of the colon and its mesocolon from the margins of the hernia defect. The colon is pulled intraabdominally, thus reducing a prolaps if present. The colon is then pulled to the lateral side of the hernia defect. We fix the colon with some resorbable sutures between the serosa and the peritoneum lateral of the hernia defect. Thus we close the opening lateral of the colon.

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Fig. 2 Intraoperative view showing the mesh used for a modified Sugarbaker repair of a parastomal hernia.

Fig. 3 Intraoperative view of a laparoscopic parastomal hernia repair. The colon has been lateralised and the mesh is fixed with a transfascial suture below and above the colon.

We measure the hernia defect and check all incisions on the anterior abdominal wall for concomitant incisional hernias on these incisions. The hernia defect is drawn on to the abdomen as well as the concomitant hernias if present. A size of mesh is drawn outside these drawings so it will be large enough to cover all hernia defects by at least 5 cm in all directions (Fig. 2). If a concomitant incisional hernia is present we repair it with one large mesh covering both hernia defects. We recommend to use a mesh designed for intraperitoneal placement. Some authors have used regular polypropylene mesh intraperitoneally to repair parastomal hernias (12). Most authors think this harbours the risk for extensive adhesions, bowel fistula and mesh infection. We use an ePTFE mesh (Dualmesh Plus with Holes , WL Gore, Flagstaff, Arizona, USA) in our practice. When the mesh has been cut to the appropriate size and form, orientation marks are made on the mesh and on the abdominal wall to allow orientation of the mesh once it has been placed intraperitoneally. At the orientation marks the first sutures are placed before the mesh is inserted into the abdomen. When introducing the mesh, contact with the skin should be avoided. Therefore the meshes of moderate size are introduced trough a trocar. Larger meshes that are too big to introduce through a trocar are rolled inside the sterile plastic covering of the mesh and are introduced after removal of the trocar. Inside the abdomen the mesh is removed from its plastic covering, which is than removed from the abdomen. The mesh is orientated using the orientation marks and the sutures are extracted with a suture passer technique through separate small skin incisions at the orientation marks. The sutures are tied down to the anterior abdominal fascia, thus creating transabdominal fixation

Fig. 4 Fixation of the mesh in a laparoscopic parastomal hernia repair with a modified Sugarbaker technique. We use a combination of transfascial fixation sutures and spiral tackers in a double crown configuration.

sutures. We place a transfascial fixation suture laterally in the mesh just above and just underneath the lateralised bowel (Fig. 3). Care is taken not to injure the bowel. Further sutures are placed all around the mesh at 5 cm intervals at the margin of the mesh. Further fixation is done with a mechanical fixation device at the margin of the mesh with an interval of one to two cm between the fixations. We use spiral tackers (Protack, Autosuture, Tyco Health Care Group, Norwalk, Connecticut, USA) as a fixation device. Then a second row of staplers is placed at the margin of the hernia

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defect like for a double crown fixation. With some additional staplers we connect these two rows of staplers at each side of the colon. Again care is taken not to put staplers into the colon or the mesocolon. Our method of mesh fixation is explained graphically in Fig. 4. Results After having seen a live surgery session where Karl Leblanc performed a laparoscopic modified Sugarbaker technique to treat a parastomal hernia we adopted this technique since November 2005 in all patients presenting with an indication for repair. We have operated five consecutive patients with a symptomatic parastomal hernia. All patients had a left sided colostomy. Two for adenocarcinoma of the rectum and three for benign rectal disease leading to a permanent colostomy. For four patients this was the first time their parastomal hernia was repaired. One patient had two previous repairs, the last one including a mesh repair in the retromuscular position. In four patients a concomitant incisional hernia, either on the midline or at an old ileostomy site, was repaired. Indications were incarceration in one and recurrent obstructions in four. All patients were treated with one intact ePTFE mesh covering the parastomal hernia, the lateralised colon and the concomitant incisional hernia, if present. There were no intraoperative or postoperative complications. Till today, no recurrence has been observed, although follow-up is rather short. No problems with stenosis or obstructions of the colostomy have been encountered and colonic irrigation is either as good or better than preoperatively. We plan to do a prospective multicenter follow-up study of laparoscopic modified Sugarbaker repair to repair parastomal hernias to obtain long-term results of this technique. We will focus on recurrences and functional outcome. Discussion Some reports with keyhole techniques have disappointing results with high recurrence rates. Safadi reported a recurrence rate of 56% (5/9 patients) within 6 months of the operation (7). They recommended changes in the technique of laparoscopic parastomal hernia repair to achieve better results. Initial results with laparoscopic parastomal hernia repair using a Keyhole technique in our experience were disappointing. Analysis of the recurrences showed that the weak point of the repair was the hole in the mesh. It is indeed difficult to estimate the appropriate size for the hole in the mesh, that optimally accommodates the colon going to the skin. From experience with laparoscopic incisional hernia repair we know that the

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amount of overlap of the mesh beyond the hernia defect is an important determinant for the risk of hernia recurrence. In a Keyhole technique the amount of overlap at the hole is zero. Therefore this will always be a weak point for developing recurrences. Moreover we know that an implanted mesh shows a variable degree of shrinkage. Shrinkage of a mesh with a central hole will result in enlargement of this hole. These disappointing results are similar to some results in the literature with Keyhole techniques. Tessier analysed the literature on laparoscopic parastomal hernia repair and compared the Sugarbaker with the Keyhole techniques (16). He concluded that the Sugarbaker technique is superior to the Keyhole technique by offering decreased operating time, lower morbidity, shorter length of stay and less recurrence rate. LEBLANC et al., in their most recent paper on laparoscopic parastomal hernia repair, feel that the single patch technique as an onlay repair is the better alternative compared to the keyhole techniques (14). We currently prefer the modified Sugarbaker technique to repair parastomal hernias laparoscopically. Not only are we convinced that the recurrence rates will be lower, but also that this technique is definitely much easier to perform. It is a laparoscopic adaptation of the open technique performed by Stelzner, that has proven its efficacy,with good long term results. Conclusion Laparoscopic repair of parastomal hernias is a safe and feasible technique. In our experience laparoscopic parastomal hernia repair with keyhole techniques had a disappointing high recurrence rate. Therefore we changed to a laparoscopic Sugarbaker technique with promising early results.

References
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10. STELZNER S., HELLMICH G., LUDWIG K. Repair of paracolostomy hernias with a prosthetic mesh in the intraperitoneal onlay position : modified Sugarbaker technique. Dis Colon Rectum, 2004, 47 : 185-91. 11. PORCHERON J., PAYAN B., BALIQUE J. G. Mesh repair of paracolostomal hernia by laparoscopy. Surg Endosc, 1998, 12 : 1281. 12. VOITK A. Simple technique for laparoscopic paracolostomy hernia repair. Dis Colon Rectum, 2000, 43 : 1451-3. 13. BERGER D. Laparoscopic paraostomal hernia repair : indications, technique and results. In : Morales-Conde S. (ed.). Laparoscopic ventral hernia repair. Springer Verlag France, 2002, pp. 383-7. 14. LEBLANC K. A., BELLANGER D. E., WHITAKER J. M., HAUSMANN M. G. Laparoscopic parastomal hernia repair. Hernia, 2005, 9 : 140-4. 15. HANSSON B. M., DE HINGH I. H., BLEICHRODT R. P. Laparoscopic parastomal hernia repair is feasible and safe : early results of a

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prospective clinical study including 55 consecutive patients. Surg Endosc, 2007, Mar 13 : Epub ahead of print. 16. TESSIER D. J. A comparison of laparoscopic parastomal hernia repair using the Sugarbaker and Keyhole techniques. 2006 Abstract P-26, 3rd International Hernia Congress, Boston.

Dr. Filip Muysoms AZ Maria Middelares Kortrijksesteenweg 1026 B-9000 Gent, Belgium Tel. : 003292607181 Fax : 003292607175 E-mail : filip.muysoms@azmmsj.be