Parastomal hernias

Single-port parastomal hernia repair by using 3-D textile implants

Background:

Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall.

Methods:

We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications.

Results:

From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively.

Conclusion:

We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.

Patient-related factors influence the risk of developing intestinal stoma complications in early post-operative period

BACKGROUND

Few studies have investigated the risk factors associated with developing intestinal stoma complications using appropriate multivariable methods. We aimed to determine the prevalence of, and risk factors for, stomal complications.

METHODS

A retrospective, case-control methodology was used to investigate 12 explanatory variables and four outcome variables in 202 consecutive patients receiving stomas in a district general hospital in the United Kingdom between January 2013 and December 2014. Univariable and multivariable logistic regression were used to calculate odds ratios (ORs).

RESULTS

There were 69 complications (69/202; 34.2%) in the early post-operative period (median 12 months) in total, the most common being retraction (30.4%). Performance status (World Health Organization score 1 or more; OR 2.67; 95% confidence intervals (CIs) 1.33-5.33; P = 0.006) and body mass index (>30 kg/m² ; OR 3.30; 95% CIs 1.61-6.78; P = 0.001) were significantly associated with developing complications in multivariable analysis. Surgery-related risk factors, such as time of day or week of operation and grade of surgeon, were not associated with the development of stoma complications. Thirty-eight patients (18.8%) died over the follow-up period, but mortality was not related to the development of stoma complications (1.01; 0.48-2.13, P = 0.98).

CONCLUSION

Patient-related risk factors influence the risk of developing a stoma complication more than surgery-related risk factors. Preoperative and post-operative interventions, planning, vigilance and management should be focussed to at-risk groups, particularly obese patients.

Prophylactic stoma mesh did not prevent parastomal hernias

PURPOSE

Parastomal herniation is reported in up to 50 % of patients with a colostomy. A prophylactic stoma mesh has been reported to reduce parastomal hernia rates. The aim of the study was to evaluate the rate of parastomal hernias in a population-based cohort of patients, operated with and without a prophylactic mesh at two different time periods.

METHODS

All rectal cancer patients operated with an abdominoperineal excision or Hartmann's procedure between 1996 and 2012 were included. From 2007, a prophylactic stoma mesh was placed in the retro-muscular plane. Patients were followed prospectively with clinical and computed tomography examinations.

RESULTS

There were no differences with regard to age, gender, pre-operative albumin levels, ASA score, body mass index (BMI), smoking or type of surgical resection between patients with (n = 71) and without a stoma mesh (n = 135). After a minimum follow-up of 1 year, 187 (91%) of the patients were alive and available for analysis. At clinical and computed tomography examinations, exactly the same parastomal hernia rates were found in the two groups, viz, 25 and 53%, respectively (p = 0.95 and p = 0.18). The hernia sac contained omentum or intestinal loops in 26 (81%) versus 26 (60%) patients with and without a mesh, respectively (p = 0.155). In the multivariate analyses, high BMI was associated with parastomal hernia formation.

CONCLUSIONS

A prophylactic stoma mesh did not reduce the rate of clinically or computed tomography-verified parastomal hernias. High BMI was associated with an increased risk of parastomal hernia formation regardless of prophylactic stoma mesh.

Modified laparoscopic Sugarbaker repair decreases recurrence rates of parastomal hernia

BACKGROUND

Parastomal hernia (PH) is a frequent complication of stoma formation, and recurrence after repair is common. A laparoscopic modified Sugarbaker technique (SB) may decrease the recurrence of PH compared with other methods.

METHODS

A retrospective review, approved by the institutional review board, of patients who underwent PH repair between 2004 and 2014 was performed. Demographics, factors for ostomy formation, hernia risk factors, intraoperative and postoperative information, and recurrence data were compared among SB and other techniques. Time to recurrence was compared between SB versus other techniques with the Kaplan-Meier method and adjusted Cox proportional hazards regression modeling.

RESULTS

Sixty-two PH repairs were performed: 39 (61%) paraileostomy and 23 (39%) paracolostomy. Repairs included 25 laparoscopic modified SB and 37 from other techniques. There was no difference in demographics. Postoperative complication rate was lesser in SB versus all other groups (40% vs 76%, P = .02). Recurrence rates were lesser for SB versus all others (16% vs 60%, P < .001). Follow-up was similar among all groups. After adjustment, SB was found to be protective of recurrences (hazard ratio = .28, 95% confidence interval = 0.09-0.82).

CONCLUSION

A laparoscopic modified SB technique provides decreased rates of recurrence and postoperative complications compared with other approaches.

Current state of laparoscopic parastomal hernia repair: A meta-analysis

AIM: To evaluate the efficacy and safety of the laparoscopic approaches for parastomal hernia repair reported in the literature.

METHODS: A systematic review of PubMed and MEDLINE databases was conducted using various combination of the following keywords: stoma repair, laparoscopic, parastomal, and hernia. Case reports, studies with less than 5 patients, and articles not written in English were excluded. Eligible studies were further scrutinized with the 2011 levels of evidence from the Oxford Centre for Evidence-Based Medicine. Two authors reviewed and analyzed each study. If there was any discrepancy between scores, the study in question was referred to another author. A meta -analysis was performed using both random and fixed-effect models. Publication bias was evaluated using Begg’s funnel plot and Egger’s regression test. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications. Studies were grouped by operative technique where indicated. Except for recurrence, most postoperative morbidities were reported for the overall cohort and not by approach so they were analyzed across approach.

RESULTS: Fifteen articles with a total of 469 patients were deemed eligible for review. Most postoperative morbidities were reported for the overall cohort, and not by approach. The overall postoperative morbidity rate was 1.8% (95%CI: 0.8-3.2), and there was no difference between techniques. The most common postoperative complication was surgical site infection, which was seen in 3.8% (95%CI: 2.3-5.7). Infected mesh was observed in 1.7% (95%CI: 0.7-3.1), and obstruction requiring reoperation also occurred in 1.7% (95%CI: 0.7-3.0). Other complications such as ileus, pneumonia, or urinary tract infection were noted in 16.6% (95%CI: 11.9-22.1). Eighty-one recurrences were reported overall for a recurrence rate of 17.4% (95%CI: 9.5-26.9). The recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, whereas the recurrence rate was 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

CONCLUSION: Laparoscopic intraperitoneal mesh repair is safe and effective for treating parastomal hernia. A modified Sugarbaker approach appears to provide the best outcomes.

New minimally invasive technique of parastomal hernia repair - methods and review

INTRODUCTION

Parastomal hernia is described as the most common complication in patients with ostomy. It is reported that its incidence varies from 3% to 39% for colostomies and 0 to 6% for ileostomies. Surgical repair remains the treatment of choice. There are three types of surgical treatment - fascial repair, stoma relocation and repair using prosthetic mesh via a laparoscopic or open approach. Recently there have been several meta-analyses and systematic reviews aiming to compare the results of surgical treatment, and the authors agreed that the quality of evidence precludes firm conclusions.

AIM

To describe the novel concept of parastomal hernia repair - HyPER/SPHR technique (hybrid parastomal endoscopic re-do/Szczepkowski parastomal hernia repair) and its early results in 12 consecutive cases.

MATERIAL AND METHODS

Twelve consecutive patients were operated on due to parastomal hernia using the new HyPER hybrid technique between June 2013 and May 2014. The patients' condition was evaluated during the perioperative period, 6 weeks and then every 3 months after surgery.

RESULTS

After 6 weeks of follow-up we have not observed any mesh-related complications. All 12 patients were examined 3 months and 6 months after repair surgery for evaluation. No recurrence, stoma site infection or stoma-related problems were found. None of the patients complained of pain and none of them needed to be hospitalized again. Reported quality of life on a 0-10 scale after 6 weeks of follow-up was 8 (range: 7-10).

CONCLUSIONS

The HyPER procedure for treatment of parastomal hernias proposed by the authors is a safe and feasible surgical technique with a high patient satisfaction rate and a low number of complications. The hybrid procedure seems to be a promising method for parastomal hernia repair.

Parastomal hernia repair

Parastomal herniation is a common clinical occurrence. Historically, there has been a high recurrence rate after repair, and conservative management is usually recommended for patients with mild symptoms. When operative intervention is warranted, we opt for a laparoscopic mesh sublay over the fascial defect and lateralization of the stoma limb, or the Sugarbaker technique. In patients who are considered poor risk for laparoscopy/laparotomy requiring repair, we perform a fascial onlay with mesh utilizing an anterior circumstomal approach.

The influence of laparoscopy on incisional hernia rates: a retrospective analysis of 1057 colorectal cancer resections

AIM

The aim of this study was to evaluate the incidence of incisional hernia formation after laparoscopic and open surgery for colorectal cancer.

METHOD

A retrospective analysis was conducted of 1057 colorectal cancer resection cases (289 laparoscopic, 768 open) performed in a single national laparoscopic training centre between January 2006 and December 2011. Clinical notes and serial computed tomography scans were reviewed, with any incisional hernia including those at a surgical incision, port site, stoma and stoma closure site identified and the size of the defect measured.

RESULTS

The overall incisional hernia rate was 14.8%. There was no significant difference between the open and laparoscopic groups (14.4% vs 15.9%, P = 0.566). Excluding stoma-related hernia, 10.7% of the open group developed a surgical wound hernia, and 11.1% of the laparoscopic group developed a hernia at a port site, extraction site or surgical midline incision. There was no statistical difference between the two groups (P = 0.853). The defects were smaller in the laparoscopic group (P < 0.005). There were significantly more parastomal hernias in the laparoscopic group (40%) than in the open group (12.7%, P < 0.001).

CONCLUSION

The incidence of incisional hernia formation was similar after laparoscopic or open surgery for colorectal cancer. Parastomal hernia was more frequent after laparoscopic surgery.

Single-center experience with parastomal hernia repair using retromuscular mesh placement

BACKGROUND

Parastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement.

METHODS

From 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences.

RESULTS

There were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m(2). Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n = 29), lightweight polypropylene (n = 15), or absorbable synthetic mesh (n = 2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11%) developed a recurrence; three patients required re-repair.

CONCLUSION

In this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.

Short- and long-term outcomes of incarcerated inguinal hernias repaired by Lichtenstein technique

Introduction

The use of tension-free inguinal hernia repair techniques using commercially available implants is now rather common. However, it is widely accepted that the use of biomaterials should be limited to non-infected surgical fields. As such, most current studies pertain to the application of various implants during the surgical repair of uncomplicated hernias.

Aim

To compare the short- and long-term outcomes of incarcerated inguinal hernia repair using the Lichtenstein or Bassini technique.

Material and methods

Between 1997 and 2012, 107 patients were operated on an emergency basis due to the incarceration of inguinal hernias – 105 subjects were included for further analysis in our study.

Results

Postoperative complications were observed in 13 out of the 84 (15.5%) patients subjected to Lichtenstein repair. In 9 of these patients (10.7%), morbidity was associated with the surgical wound. In 2 cases (2.4%), a small inflammatory infiltration was observed and resolved within a few days. Serous fluid accumulation within the wound was observed in 3 patients (3.6%), but the fluid was successfully drained by puncture. Finally, hematoma formed in 4 cases (4.8%). In total, 4 complications (19%) were recorded in the group of 21 patients who were operated on with the Bassini technique. In 3 of these cases (14.3%), the complications were related to suppuration of the surgical wound.

Conclusions

Polypropylene mesh may be safely implanted during the repair of incarcerated hernia and this approach is reflected by satisfactory long-term outcomes.

Avoidance and management of stomal complications

The construction of an intestinal stoma is fraught with complications and should not be considered a trivial undertaking. Serious complications requiring immediate reoperations can occur, as can minor problems that will subject the patient to daily and nightly distress. Intestinal stomas undoubtedly will dramatically change lifestyles; patients will experience physiologic and psychologic detriment with stoma-related problems, however minor they may seem. Common complications include poor stoma siting, high output, skin irritation, ischemia, retraction, parastomal hernia (PH), and prolapse. Surgeons should be cognizant of these complications before, during, and after stoma creation, and adequate measures should be taken to avoid them. In this review, the authors highlight these often seen problems and discuss management and prevention strategies.

[Median incisional hernias and coexisting parastomal hernias : new surgical strategies and an algorithm for simultaneous repair]

The co-occurrence of incisional and parastomal hernias (PSH) remains a surgical challenge. Standardized treatment guidelines are missing, and the patients concerned require an individualized surgical approach. The laparoscopic techniques can be performed with incised and/or stoma-lateralizing flat meshes with intraperitoneal onlay placement. The purely laparoscopic and laparoscopic-assisted approaches with 3-D meshes offer advantages regarding the complete coverage of the edges of the stomal areas and the option of equilateral or contralateral stoma relocation in cases of PSH, which are difficult to handle due to scarring, adhesions, and large fascial defects > 5 cm with intestinal hernia sac contents. A relevant stoma prolapse can be relocated by tunnel-like preformed 3-D meshes and shortening the stoma bowel. The positive effect on prolapse prevention arises from the dome of the 3-D mesh, which is directed toward the abdominal cavity and tightly fits to the bowel. In cases of large incisional hernias (> 8-10 cm in width) or young patients with higher physical demands, an open abdominal wall reconstruction in sublay technique is required. Component separation techniques that enable tension-free ventral fascial closure should be preferred to mesh-supported defect bridging methods. The modified posterior component separation with transversus abdominis release (TAR) and the minimally invasive anterior component separation are superior to the original Ramirez technique with respect to wound morbidity. By using 3-D textile implants, which were specially designed for parastomal hernia prevention, the stoma can be brought out through the lateral abdominal wall without increased risk of parastomal hernia or prolapse development. An algorithm for surgical treatment, in consideration of the complexity of combined hernias, is introduced for the first time.

A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies

BACKGROUND

A large proportion of patients with a colostomy or an ileostomy develop parastomal hernias. The placement of a reinforcing material at the stoma site may reduce parastomal hernia incidence.

OBJECTIVE

We aimed to assess the safety and efficacy of stoma reinforcement with sublay placement of non-cross-linked porcine-derived acellular dermal matrix at the time of stoma construction.

DESIGN

This is a randomized, patient- and third-party assessor-blind, controlled trial.

SETTINGS

This study took place in colorectal/general surgery institutions.

INTERVENTIONS

Patients were prospectively randomly assigned to undergo standard end-stoma construction with or without porcine-derived acellular dermal matrix reinforcement.

PATIENTS

Patients undergoing construction of a permanent stoma were eligible. A total of 113 patients (59 men, 54 women; mean age, 60 years; mean BMI, 25.4 kg/m) participated: 58 controls and 55 with reinforcement.

MAIN OUTCOMES MEASURES

The incidence of parastomal hernia, safety, and stoma-related quality of life were assessed.

RESULTS

Intraoperative complications and blood loss were similar between groups. Quality-of-life scores were similar through 24 months of follow-up. At 24 months of follow-up, the incidence of parastomal hernias was similar for both groups (12.2% of the porcine-derived acellular dermal matrix group and 13.2% of controls).

LIMITATIONS

Study limitations include the inclusion of ileostomy and colostomy patients, open and laparoscopic techniques, and small numbers of patients at follow-up.

CONCLUSIONS

Safety and quality-of-life data from this randomized control trial show similar outcomes in both groups. Prosthetic reinforcement of stomas was safe, but it did not significantly reduce the incidence of parastomal hernia formation.

CLINICAL TRIAL REGISTRATION

Identification no. NCT00771407.

Strangulated ileostomy evisceration following lateralizing mesh repair of parastomal hernia

Parastomal hernia formation and ostomy prolapse are relatively common complications of intestinal ostomy construction. Underlay mesh placement with lateralization of the stoma limb appears to be the method of repair with the lowest recurrence rate. Prophylaxis of new stomas with mesh is advocated by many authors. We report the case of an 81-year-old man with chronic steroid-dependent COPD who presented to the emergency department with strangulated small bowel evisceration 9 days following completion abdominal colectomy, and creation of an end ileostomy reinforced with intraperitoneal mesh. This rare complication was related to this patient's risk factors for poor healing including poor nutrition, age, chronic COPD and coughing and steroid dependence with immunosuppression.

Paracolostomy hernia repair: who and when?

BACKGROUND

Paracolostomy hernia repair (PHR) can be a challenging procedure associated with significant morbidity and high recurrence rates. We sought to analyze the complication rate and 30-day mortality among patients undergoing PHR.

STUDY DESIGN

This is a retrospective analysis of patients with PHR, based on Current Procedural Terminology code 44346, using the NSQIP database from 2005 to 2008. Univariate analysis of 30-day outcomes after both emergent and nonemergent PHR in patients greater than or less than 70 years old was completed.

RESULTS

There were 519 patients who underwent PHR (mean age, 63.9 years old, female, 55.9%). Emergency PHR, performed in 59 patients (11.4%), was associated with increased rates of organ space surgical site infection (SSI) (8.5% vs 0.9%, p = 0.0014), pneumonia (18.6% vs 2.6%, p ≤ 0.0001), septic shock (13.6% vs 2.6%, p = 0.0007), total morbidity (50.8% vs 2.6%, p ≤ 0.0001), and death (10.2% vs 0.9%; p = 0.0002). In patients older than 70 years, emergent PHR amplified these differences: organ space SSI (13.8% vs 1.2%, p = 0.0054); pneumonia (27.6% vs 3.7%; p = 0.0002), septic shock (17.2% vs 4.3%; p = 0.02), and mortality (20.7% vs 1.9%; p = 0.0005).

CONCLUSIONS

This study revealed that most PHRs are performed electively. Although elective repair remains a relatively safe procedure, even in the elderly, emergency PHR is associated with increased morbidity, especially pulmonary and septic complications, and higher mortality. These results are amplified among patients older than 70 years undergoing emergent repair. These findings suggest that greater consideration should be given to elective repair of paracolostomy hernias in the elderly because emergency repair is associated with considerable risk and worse outcomes.

Risk factors for the development of parastomal hernia after radical cystectomy

PURPOSE

Parastomal hernia is a frequent complication of stoma formation after radical cystectomy. We determined the prevalence and risk factors for the development of parastomal hernia after radical cystectomy.

MATERIALS AND METHODS

We conducted a retrospective study of 433 consecutive patients who underwent open radical cystectomy and ileal conduit between 2006 and 2010. Postoperative cross-sectional imaging studies performed for routine oncologic followup (1,736) were evaluated for parastomal hernia, defined as radiographic evidence of protrusion of abdominal contents through the abdominal wall defect created by forming the stoma. Univariable and multivariable Cox regression analyses were used to determine clinical and surgical factors associated with parastomal hernia.

RESULTS

Complete data were available for 386 patients with radiographic parastomal hernia occurring in 136. The risk of a parastomal hernia developing was 27% (95% CI 22, 33) and 48% (95% CI 42, 55) at 1 and 2 years, respectively. Clinical diagnosis of parastomal hernia was documented in 93 patients and 37 were symptomatic. Of 16 patients with clinical parastomal hernia referred for repair 8 had surgery. On multivariable analysis female gender (HR 2.25; 95% CI 1.58, 3.21; p<0.0001), higher body mass index (HR 1.08 per unit increase; 95% CI 1.05, 1.12; p<0.0001) and lower preoperative albumin (HR 0.43 per gm/dl; 95% CI 0.25, 0.75; p=0.003) were significantly associated with parastomal hernia.

CONCLUSIONS

The overall risk of radiographic evidence of parastomal hernia approached 50% at 2 years. Female gender, higher body mass index and lower preoperative albumin were most associated with the development of parastomal hernia. Identifying those at greatest risk may allow for prospective surgical maneuvers at the time of initial surgery, such as placement of prophylactic mesh in selected patients, to prevent the occurrence of parastomal hernia.

Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation

BACKGROUND

A parastomal hernia is defined as an incisional hernia related to a stoma and belongs to the most common stoma-related complications. Many factors concerning the operative technique which are considered to influence the incidence of parastomal herniation have been investigated. However, it remains unclear whether the enterostomy should be placed through or lateral to the rectus abdominis muscle in order to prevent parastomal herniation and other important stoma complications for people undergoing abdominal wall enterostomy.

OBJECTIVES

To assess if there is a difference regarding the incidence of parastomal herniation and other stomal complications, such as ileus and stenosis, in lateral pararectal versus transrectal stoma placement in people undergoing elective or emergency abdominal wall enterostomy.

SEARCH METHODS

In October and November 2012 we searched for all types of published and unpublished randomized and non-randomized studies with no restriction on language, date or country (search dates in brackets). We searched the bibliographic databases The Cochrane Library (4 October 2012), MEDLINE (1 October 2012), EMBASE (10 October 2012), LILACS (29 November 2012), and Science Citation Index Expanded (4 October 2012). We also searched the reference lists of all relevant studies and the trial registers ClinicalTrials.gov (9 October 2012), World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal (10 October 2012), as well as three additional trial registers not included in the ICTRP (27 November 2012).

SELECTION CRITERIA

Randomized and non-randomized studies comparing lateral pararectal versus transrectal stoma placement with regard to parastomal herniation and other stoma-related complications.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Data analyses were conducted according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Cancer Group (CCCG). Quality of evidence was rated according to GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

Nine retrospective cohort studies with a total of 761 participants met the inclusion criteria. All included studies reported results for the primary outcome (parastomal herniation), and one study also reported data on one of the secondary outcomes (stomal prolapse). None of the included studies compared the two interventions with regard to other secondary outcomes.There was neither a significant difference in terms of the risk for parastomal herniation (risk ratio (RR) 1.29; 95% confidence interval (CI) 0.79 to 2.1) nor with regard to the occurrence of stomal prolapse (RR 1.23; 95% CI 0.39 to 3.85). An I² value of 65% indicated substantial statistical heterogeneity in the meta-analysis.

AUTHORS' CONCLUSIONS

The poor quality of the included evidence does not allow a robust conclusion regarding the objectives of the review. This review highlights a clear uncertainty as to the relative merits of either approach. There is a need for randomized trials to evaluate the effectiveness of the lateral pararectal versus the transrectal approach in preventing parastomal herniation and other stoma-related morbidity in people requiring enterostomy placement.

[Hernia surgery in urology. Part 2: parastomal, trocar and incisional hernias - fundamentals of clinical diagnostics and treatment]

Hernias are a common occurrence with a correspondingly huge clinical and economic impact on the healthcare system. Parastomal and trocar hernias are rare in routine urological work. The therapy of parastomal hernias remains problematic but basically the surgeon is able to use conventional techniques with suture repair or procedures with mesh implantation. The conventional parastomal hernia repair with mesh can be classified into sublay, onlay and intraperitoneal techniques. Furthermore, a relocation of the stoma is possible. Trocar hernias represent a rare but hazardous complication. Due to the increase in keyhole surgery there is also the danger of a rise in their occurrence. Incisional hernias occur frequently in patients who have undergone laparotomy and for repair different surgical techniques and types of meshes are available. This article presents an overview of the epidemiology, pathogenesis, clinical symptoms, diagnostic and therapy of parastomal, trocar and incisional hernias.

Management and complications of stomas

Stomas are created for a wide range of indications such as temporary protection of a high-risk anastomosis, diversion of sepsis, or permanent relief of obstructed defecation or incontinence. Yet this seemingly benign procedure is associated with an overall complication rate of up to 70%. Therefore, surgeons caring for patients with gastrointestinal diseases must be proficient not only with stoma creation but also with managing postoperative stoma-related complications. This article reviews the common complications associated with ostomy creation and strategies for their management.

Incidence and risk factors of parastomal hernia

Purpose

Among the various stoma complications, the parastomal hernia (PSH) is the most common. Prevention of PSH is very important to improve the quality of life and to prevent further serious complications. The aim of this study was to analyze the incidence and the risk factors of PSH.

Methods

From January 2002 and October 2008, we retrospectively reviewed 165 patients who underwent an end colostomy. As a routine oncologic follow-up, abdomino-pelvic computed tomography was used to examine the occurrence of the PSH. The associations of age, sex, body mass index (BMI), history of steroid use and comorbidities to the development of the PSH were analyzed. The median duration of the follow-up was 36 months (0 to 99 months).

Results

During follow-up, 50 patients developed a PSH and the 5-year cumulative incidence rate of a PSH, obtained by using the Kaplan-Meier method, was 37.8%. In the multivariate COX analysis, female gender (hazard ratio [HR], 3.29; 95% confidence interval [CI], 1.77 to 6.11; P < 0.0001), age over 60 years (HR, 2.37; 95% CI, 1.26 to 4.46; P = 0.01), BMI more than 25 kg/m² (HR, 1.8; 95% CI, 1.02 to 3.16; P = 0.04), and hypertension (HR, 2.08; 95% CI, 1.14 to 3.81; P = 0.02) were all independent risk factors for the development of a PSH.

Conclusion

The 5-year incidence rate of a PSH was 37.8%. The significant risk factors of a PSH were as follows: female gender, age over 60 years, BMI more than 25 kg/m², and hypertension. Using a prophylactic mesh during colostomy formation might be advisable when the patients have these factors.

The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study

BACKGROUND

Parastomal hernia is a frequent complication of intestinal stomata. Mesh repair gives the best results, with the mesh inserted via laparotomy or laparoscopically. It was the aim of this retrospective multicenter study to determine the early and late results of the laparoscopically performed, modified Sugarbaker technique with ePTFE mesh.

METHODS

From 2005 to 2010, a total of 61 consecutive patients (mean age = 61 years), with a symptomatic parastomal hernia, underwent laparoscopic repair using the modified Sugarbaker technique with ePTFE mesh. Fifty-five patients had a colostomy, 4 patients an ileostomy, and 2 a urostomy according to Bricker. The records of the patients were reviewed with respect to patient characteristics, postoperative morbidity, and mortality. All patients underwent physical examination after a follow-up of at least 1 year to detect a recurrent hernia. Morbidity rate was 19 % and included wound infection (n = 1), ileus (n = 2), trocar site bleeding (n = 2), reintervention (n = 2), and pneumonia (n = 1). One patient died in the postoperative period due to metastasis of lung carcinoma that caused bowel obstruction. Concomitant incisional hernias were detected in 25 of 61 patients (41 %) and could be repaired at the same time in all cases. A recurrent hernia was found in three patients at physical examination, and in one patient an asymptomatic recurrence was found on a CT scan. The overall recurrence rate was 6.6 % after a mean follow-up of 26 months.

CONCLUSION

The laparoscopic Sugarbaker technique is a safe procedure for repairing parastomal hernias. In our study, the overall morbidity was 19 % and the recurrence rate was 6.6 % after a mean follow-up of 26 months. Moreover, the laparoscopic approach revealed concomitant hernias in 41 % of the patients, which could be repaired successfully at the same time.

Incarcerated internal hernia within a huge irreducible parastomal hernia with intestinal obstruction: a rare case report of "hernia within hernia"

We report an incarcerated internal hernia in a huge irreducible parastomal hernia-"hernia within hernia." A 70-year-old obese woman with diabetes who underwent an abdomino-perineal resection 20 years ago was admitted to our hospital with 20 years history of a huge irreducible bulge, 25 cm in diameter. An internal hernia due to an adhesive band extending from the sac wall to proximal colon was found in the parastomal hernia sac during an emergency laparotomy. We cut off the distal colon and relocated the colostomy stoma. The patient was discharged uneventfully 2 weeks after the surgery and was readmitted to have a further laparoscopic hernia repair 8 months later. Unfortunately, an unrecognized enterotomy occurred during the secondary surgery that led to an additional laparotomy during which the mesh was not contaminated by the bowel contents and was kept in place. At 22-month follow-up, there were no evidences of recurrence.

Surgical techniques for parastomal hernia repair: a systematic review of the literature

BACKGROUND

Parastomal hernias are a frequent complication of enterostomies that require surgical treatment in approximately half of patients. This systematic review aimed to evaluate and compare the safety and effectiveness of the surgical techniques available for parastomal hernia repair.

METHODS

Systematic review was performed in accordance with PRISMA. Assessment of methodological quality and selection of studies of parastomal hernia repair was done with a modified MINORS. Subgroups were formed for each surgical technique. Primary outcome was recurrence after at least 1-year follow-up. Secondary outcomes were mortality and postoperative morbidity. Outcomes were analyzed using weighted pooled proportions and logistic regression.

RESULTS

Thirty studies were included with the majority retrospective. Suture repair resulted in a significantly increased recurrence rate when compared with mesh repair (odds ratio [OR] 8.9, 95% confidence interval [CI] 5.2-15.1; P < 0.0001). Recurrence rates for mesh repair ranged from 6.9% to 17% and did not differ significantly. In the laparoscopic repair group, the Sugarbaker technique had less recurrences than the keyhole technique (OR 2.3, 95% CI 1.2-4.6; P = 0.016). Morbidity did not differ between techniques. The overall rate of mesh infections was low (3%, 95% CI 2) and comparable for each type of mesh repair.

CONCLUSIONS

Suture repair of parastomal hernia should be abandoned because of increased recurrence rates. The use of mesh in parastomal hernia repair significantly reduces recurrence rates and is safe with a low overall rate of mesh infection. In laparoscopic repair, the Sugarbaker technique is superior over the keyhole technique showing fewer recurrences.

Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized controlled trial

PURPOSE

Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia.

METHODS

Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis.

RESULTS

Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50 % of patients in the mesh group and in 93.8 % of patients in the control group (P = 0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (P = 0.004) and the optimal threshold 23 mm. Subcutaneous fat thickness ≥23 mm was a significant predictor of parastomal hernia (odds ratio 15.7, P = 0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06, P = 0.031).

CONCLUSIONS

Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ≥23 mm measured by CT was an independent predictor of parastomal hernia.

A rare stoma-related complication: parastomal evisceration

Defunctioning stoma is a commonly used colorectal surgical procedures. The stomal complications recorded are usually classified as early and late complications. Parastomal hernia is a common complication of stomal surgery. We present a very rare stoma-related complication developed after parastomal hernia and described parastomal evisceration.

Dehydration is the most common indication for readmission after diverting ileostomy creation

BACKGROUND

Early readmission after discharge from the hospital is an undesirable outcome. Ileostomies are commonly used to prevent symptomatic anastomotic complications in colorectal resections.

OBJECTIVE

The aim of this study was to identify factors predictive of readmission after colectomy/proctectomy and diverting loop ileostomy.

DESIGN

This study is a retrospective review.

PATIENTS

Patients were included who underwent colon and rectal resections with ileostomy at our institution. Sex, age, type of disease, comorbidities, elective vs urgent procedure, type of ileostomy, operative method, steroid use, ASA score, and the use of diuretics were evaluated as potential factors for readmission.

MAIN OUTCOME MEASURES

The primary outcomes measured were the need for readmission and the presence of dehydration (ostomy output ≥1500 mL over 24 hours and a blood urea nitrogen/creatinine level ≥20, or physical findings of dehydration).

RESULTS

Six hundred three loop ileostomies were created mostly in white (95.3%), male (55.6%) patients undergoing colon or rectal resections. IBD was the most common indication at 50.9%, with rectal cancer at 16.1%, and other at 31.0%. The 60-day readmission rate was 16.9% (n = 102) with the most common cause dehydration (n = 44, 43.1%). Regression analysis demonstrated that the laparoscopic approach (p = 0.02), lack of epidural anesthesia (p = 0.004), preoperative use of steroids (p = 0.04), and postoperative use of diuretics (p = 0.0001) were highly predictive for readmission. Furthermore, regression analysis for readmission for dehydration identified the use of postoperative diuretics as the sole risk factor (p = 0.0001).

LIMITATIONS

This study is limited by the retrospective analysis of data, and it does not capture patients that were treated at home or in clinic.

CONCLUSION

Readmission after colon or rectal resection with diverting loop ileostomy was high at 16.9%. Dehydration was the major cause for readmission. Patients receiving diuretics are at increased risk for readmission for dehydration. High-risk patients should be treated more cautiously as inpatients and closely monitored in the outpatient setting to help reduce dehydration and readmission.

A modified sublay-keyhole technique for in situ parastomal hernia repair

OBJECTIVE

The surgical treatment of a parastomal hernia is always challenging due to the high incidence of recurrence following primary repair, or stoma relocation and severe morbidities in prosthetic repair with polypropylene materials. We therefore developed a modified sublay-keyhole technique employing a polypropylene material to minimize the associated high risk of the procedure. We herein describe our initial clinical experience with this modified procedure.

METHODS

A retrospective review was performed to obtain the clinical data for 11 patients with parastomal hernias who underwent the modified in situ Sublay-keyhole repair from November 2008 to August 2010.

RESULTS

The mean hernia size was 58.7 cm(2) (range 30-96 cm(2)), with an average polypropylene mesh size of 376.3 cm(2) (range 270-464 cm(2)). The mean length of the operation was 147.9 min (range 120-195.0 min), and the mean postoperative hospital stay was 11 days (range 9-14 days). All patients had an uneventful incisional recovery, with no infections. Two seromas and one hematoma were found and treated with conservative management, such as with aspiration, physical therapy and compression. All patients had been followed up, with a mean length of follow-up of 23.5 months (range 11-39 months). One parastomal hernia recurrence was seen 11 months postoperatively. Breakdown of the sutures and an over-sized aperture cut in the mesh were detected as the causes of the recurrence during the secondary repair procedure. Only re-sutures in both the mesh aperture and myofascial dehiscence were executed for this patient, and no re-recurrence was observed during an additional follow-up of 15 months. No recurrence of the parastomal hernia or presentation of an incisional hernia was detected during the follow-up.

CONCLUSIONS

The modified Sublay-keyhole repair appears to be an effective procedure for parastomal hernias, with a low incidence of recurrence and risk of morbidities. Collection of more cases and further follow-up examinations will be needed to confirm our findings.

Sigmoidostomy-Related Parastomal Hernia

Background and Aims:

The aim was to examine prevalence and treatment of parastomal hernias in patients with sigmoidostomy.

Materials and Methods:

In 2009, the medical records of 447 consecutive patients operated with a sigmoidostomy from January 1999 to December 2008 were retrospectiely reviewed. 119 dead patients (26.6%) were excluded because of short follow up (n = 59) and insufficient clinical data (n = 60). 328 patients (73.4%) were followed-up, of whom 210 (64%) alive patients also were scrutinized for presence of parastomal hernia by phone interview. In 2010, 92 out of 153 alive patients (60.1%) without known parastomal hernia also underwent targeted clinical examination in the ambulatory unit.

Results and Conclusion:

Follow up from stoma operation in 328 patients was median 20 (range 1–129) months. 319 patients had an end sigmoidostomy and nine patients had a loop sigmoidostomy. Time to parastomal hernia in 66 patients (20.1%) was median 9 (1–54) months. Fourty four patients (66.7%) reported no symptoms, eight (12.1%) had mild discomfort, six (9.1%) leakage, six (9.1%) pain, and two (3%) episodes of intestinal obstruction. Eleven (16.7%) had a hernia operation, eight with onlay mesh repair complicated with bowel perforation and ventral hernia in one patient. Three with mesh repair (37.5%) developed recurrent parastomal hernia, of whom one had tissue repair and a second recurrence 6 months later. The only patient with initial tissue repair had a recurrent hernia successfully treated with mesh repair. Two patients had their stoma uneventfully reversed. Parastomal hernia rate, mainly treated with mesh repair, was fairly low in this heterogenous patient series.

Laparoscopic slit mesh repair of parastomal hernia using a designated mesh: long-term results

BACKGROUND

Parastomal hernia (PH) is a frequent complication of colorectal surgery, which incidence reaches 55% of all stoma formation. Currently, there is no definitive strategy for its repair. This study was designed to assess the outcome in patients who underwent laparoscopic PH repair using a slit mesh/keyhole technique.

METHODS

We undertook a retrospective case review of all patients who underwent laparoscopic PH repair with a designed slit mesh/keyhole between 2005 and 2010. Three ports were placed opposite the stoma site, and careful adhesiolysis and hernia content reduction were performed. The parastomal fascial defect was measured and covered with a designated mesh. Fixation of the mesh was achieved with concentric tacks and transcutaneous Prolene suture. Recurrence was diagnosed after examination of patients by two surgeons or by imaging demonstrating an indolent hernia.

RESULTS

Twenty-nine laparoscopic PH mesh repairs were performed with an average age of 63.5 (range 42-81, median 64) years to treat paracolostomy hernia in 18 of 29 cases (62.1%), para-ileostomy hernia in 10 of 29 cases (34.5%), and for an ileal conduit site hernia in 1 of 29 cases (3.4%). The average operative time was 179 (range, 80-300; median, 180) min. Two operations (6.9%) were converted to an open approach. Early postoperative complications were documented in four patients (13.8%), including one elderly patient with severe comorbidities who died from postoperative sepsis (mortality rate, 3.4%). Only one late complication was recorded (3.4%). The average hospital stay was 4.7 (range, 1-19; median, 3) days. Average follow-up time was 28 (range, 12-53; median, 30) months. Recurrence of the hernia was found in 13 of 28 patients (46.4%).

CONCLUSIONS

Laparoscopic slit mesh/keyhole repair is feasible, although it is a complex surgery reflected by extended operative time. The high recurrence rate suggests that technical improvement of the method is essential.

Laparoscopic slit mesh repair of parastomal hernia using a designated mesh: long-term results

BACKGROUND

Parastomal hernia (PH) is a frequent complication of colorectal surgery, which incidence reaches 55% of all stoma formation. Currently, there is no definitive strategy for its repair. This study was designed to assess the outcome in patients who underwent laparoscopic PH repair using a slit mesh/keyhole technique.

METHODS

We undertook a retrospective case review of all patients who underwent laparoscopic PH repair with a designed slit mesh/keyhole between 2005 and 2010. Three ports were placed opposite the stoma site, and careful adhesiolysis and hernia content reduction were performed. The parastomal fascial defect was measured and covered with a designated mesh. Fixation of the mesh was achieved with concentric tacks and transcutaneous Prolene suture. Recurrence was diagnosed after examination of patients by two surgeons or by imaging demonstrating an indolent hernia.

RESULTS

Twenty-nine laparoscopic PH mesh repairs were performed with an average age of 63.5 (range 42-81, median 64) years to treat paracolostomy hernia in 18 of 29 cases (62.1%), para-ileostomy hernia in 10 of 29 cases (34.5%), and for an ileal conduit site hernia in 1 of 29 cases (3.4%). The average operative time was 179 (range, 80-300; median, 180) min. Two operations (6.9%) were converted to an open approach. Early postoperative complications were documented in four patients (13.8%), including one elderly patient with severe comorbidities who died from postoperative sepsis (mortality rate, 3.4%). Only one late complication was recorded (3.4%). The average hospital stay was 4.7 (range, 1-19; median, 3) days. Average follow-up time was 28 (range, 12-53; median, 30) months. Recurrence of the hernia was found in 13 of 28 patients (46.4%).

CONCLUSIONS

Laparoscopic slit mesh/keyhole repair is feasible, although it is a complex surgery reflected by extended operative time. The high recurrence rate suggests that technical improvement of the method is essential.

Ultrasonographic findings in patients with peristomal bulging

AIM

The aim of this study was to obtain a classification of peristomal bulging based on findings at ultrasonography in patients with a sigmoid colostomy.

METHODS

The patient material comprised 30 men and 33 women. The median age was 69 years (28-90) and the median time between stoma creation and investigation was 68 months (3-426). Any bulging was measured, and the abdominal opening for the stoma bowel was evaluated at the clinical examination. At the ultrasonographic investigation, the patients were first investigated in the supine position to measure the transverse and vertical diameter of the abdominal opening and the thickness of the abdominal muscles.

RESULTS

Three types of ultrasonographic findings were identified. In ultra-I, the stoma bowel was completely fixed or showed telescoping-like movement through the abdominal opening. In ultra-II, fatty tissue was prolapsed together with the stoma bowel forming a bend in the subcutaneous tissue. In ultra-III, another bowel segment or fatty tissue passed beside the stoma bowel through the abdominal opening into the abdominal wall. A normal finding without any bulging at the clinical examination was associated with a smaller area and a smaller diameter of the abdominal opening than the area and diameter in patients with a visible peristomal bulging. There was no difference in the thickness of the muscle layer of the abdominal wall between patients with and without bulging.

CONCLUSIONS

Ultrasonography can make a dynamic diagnosis of parastomal hernia. In patients with visible peristomal bulging, the area of the abdominal opening is increased but there is no decrease in the thickness of the muscles of the abdominal wall.

CT and MRI features of ileostomies

OBJECTIVE

The purpose of this article is to describe CT and MRI features of normal anatomy, variants, and pathologic conditions of different ileostomies.

CONCLUSION

Multiplanar imaging techniques are useful to identify the complications related to stoma construction and preexisting disease. Understanding the indications for ileostomy construction, surgical techniques, and postoperative anatomy is important for differentiating normal and abnormal imaging features.

Experiences with a prophylactic mesh in 93 consecutive ostomies

BACKGROUND

Parastomal hernia may be present in half of patients after one year. A prophylactic low-weight prosthetic mesh in a sublay position at the index operation reduces the risk of parastomal hernia, without increasing the rate of complications.

MATERIAL

Between April 2003 and November 2006 all patients with an ostomy created at an open laparotomy were followed for at least one year.

RESULTS

A prophylactic mesh was used in 75 of 93 patients. In 9 a prophylactic mesh could not be placed due to scarring after previous surgery. In 9 a mesh was omitted after surgeon's decision. In 19 patients a mesh was used in severely contaminated wounds. With a mesh 6 of 73 (8%) patients developed a surgical site infection and without a mesh 4 of 15 (27%). With a mesh parastomal hernia was present in 8 of 61 (13%) patients and without a mesh in 8 of 12 (67%).

CONCLUSIONS

Creating a stoma in routine open surgery a prophylactic mesh can be placed in most patients. A mesh does not increase the rate of complications and can be used in severely contaminated wounds.

Systematic review of the use of a mesh to prevent parastomal hernia

BACKGROUND

Parastomal hernia is a major complication after stoma placement. Surgical procedures for repairing parastomal hernia are difficult and their failure rate is high. The use of a mesh implanted at the primary operation has shown promising results. Therefore, we performed a systematic review of the literature to evaluate the results of the placement of mesh at the time of stoma formation with the aim of preventing parastomal hernia.

METHODS

The Medline, Embase, and Cochrane Library databases were searched using the keywords "parastomal or paracolostomy hernia." Data regarding the incidence of hernia, the operative parameters, including mesh placement and types, and complications, including infection, stoma necrosis, and stenosis, were used and analyzed to evaluate the use of prophylactic mesh at the time of stoma formation.

RESULTS

Three randomized controlled trials, three prospective observational series, and one retrospective study were selected and summarized. During the follow-up period (observation time of 1-83 months), parastomal hernia was present in 32/58 patients (55%) who did not have mesh placement and in 14/179 patients (7.82%) in whom mesh was used. Meta-analysis of three randomized controlled trials showed that prophylactic use of the mesh significantly diminished the incidence of parastomal hernia (p < 0.0001). Postoperative morbidity levels were similar whether the mesh was placed or not.

CONCLUSION

Prophylactic use of mesh at the time of stoma formation is a safe procedure and reduces the risk of parastomal hernia. For more detailed evaluation, additional large, double-blinded, randomized controlled trials with long-term follow-up are necessary.

Laparoscopic versus open surgical techniques for ventral or incisional hernia repair

BACKGROUND

There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.

OBJECTIVES

We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.

SEARCH STRATEGY

We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.

SELECTION CRITERIA

We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).

MAIN RESULTS

We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I(2) = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I(2)= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.

AUTHORS' CONCLUSIONS

The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.

[Laparoscopic repair of parastomal hernia]

Parastomal hernias are a common complication after stoma formation. An exact evaluation of the history of the patients reveals clinically impairing symptoms in the majority of patients. The surgical treatment should generally be based on the augmentation or even replacement of the abdominal wall by non-resorbable meshes. The laparoscopic repair can be performed using the intraperitoneal placement of a mesh according to Sugarbaker with a wide lateralization of the stoma loop, the keyhole-technique, which means an incised mesh placed around the stoma loop, or the combination of both techniques (sandwich-technique). By far the best results can be achieved with the sandwich-technique. The recurrence rate in our series is less than 3% with an acceptable complication rate. The literature demonstrates high recurrence rates after keyhole-repair and the Sugarbaker-technique was also shown to be ineffective by our own data. In summary the laparoscopic sandwich-technique is a technically challenging but very successful method for long-lasting repair of parastomal hernias leading to an astonishingly low recurrence rate.