From keyhole to sandwich: change in laparoscopic repair of parastomal hernias at a single centre

End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches

INTRODUCTION

Parastomal hernia (PSH) is the most common and challenging complication after stoma creation, with an estimated 50% incidence 2 years after the index surgery. Mesh repair is the treatment of choice. Laparoscopic and/or robotic approaches allow acceptable outcomes.

MATERIALS AND METHODS

A systematic literature review from January 2012 to November 2023 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Embase, PubMed, and Scopus search were performed to select articles dealing with minimally invasive surgical treatment for PSH after end colostomy.

RESULTS

603 studies were found, and 24 were chosen. When compared to open surgery, laparoscopy showed decreased postoperative complications and recurrence. The main laparoscopic approaches are the keyhole (KH), the Sugarbaker (SB), and the sandwich technique. Continuous improvement in surgery, mesh technology, and surgeons' expertise led to an amelioration of surgical outcome and recurrence rate after repair. Recent studies showed comparable outcomes for SB and KH techniques, while novel surgical approaches have been proposed in an attempt to further increase the operative and long-term results. Reports on PSH robotic repairs are scarce and describe small series results, suggesting a role of the initial learning curve as a risk factor for complications.

CONCLUSION

End-colostomy PSH surgical repair still represents a challenge for surgeons. Recent evidence has not shown a significant advantage in postoperative complications and recurrence with a specific repair among SB, KH, and sandwich technique. The paucity of data on robotic surgery does not allow to draw definitive conclusion. Further primary, multicentric, and larger cohort studies are needed.

Repair of parastomal hernia after Bricker procedure: retrospective consecutive experience of a tertiary center

BACKGROUND

Ileal conduit parastomal hernias (ICPHs) are frequent after radical cystectomy with ileal conduit urinary diversion, but their management is debated. This study aimed to review the results of ICPH repair according to Sugarbaker or Sandwich techniques, with special interest in ICPH recurrence and urological complications.

METHODS

The authors reviewed a consecutive series of patients undergoing ICPH repair between January 2014 and December 2020. Primary endpoints were ICPH recurrences at clinical exam and cross-sectional abdominal computed tomography (CT) scans. Secondary endpoints were any other complications possibly related to the ICPH repair.

RESULTS

Twenty-three patients underwent ICPH repair surgery (16 Sugarbaker and 7 Sandwich techniques) during the study period. Sixteen patients underwent a primary laparoscopic approach. All but one patient underwent at least one abdominal CT during the follow-up. Median clinical and CT scan follow-up times were 57 and 50.5 months, respectively. Clinical and CT ICPH recurrence rates were 4.5% and 13% at 5 years, respectively. Eighteen patients (78%) suffered no urological complications during the follow-up period, but three patients (13%) needed redo surgery on the urinary ileal conduit.

CONCLUSION

The modified Sugarbaker or Sandwich techniques might be considered as promising techniques for ICPH repair with a low rate of recurrence. The urological complications, and particularly the ileal conduit-related issues, need to be evaluated in further studies. Controlled and prospective data are required to compare the Sugarbaker and Sandwich techniques to the Keyhole approach for ICPH repairs.

Analysis of recurrence and risk factors in laparoscopic sandwich technique for parastomal hernia repair

INTRODUCTION

Parastomal hernias are frequent and highly recurrent. The sandwich technique is a combination of the keyhole and Sugarbaker techniques, using a double intraperitoneal mesh. The objective of this study was to assess the outcomes of the sandwich technique, specifically focusing on recurrence rates.

MATERIALS AND METHODS

Observational retrospective study conducted in two tertiary referral centers in Catalonia, Spain. All consecutive patients who underwent parastomal hernia repair using the sandwich technique between 1st January 2016 and 31st December 2021 were included.

RESULTS

A total of 38 patients underwent the laparoscopic sandwich technique for parastomal hernia repair. The overall recurrence rate was 7.9% (3/38), with a median follow-up of 39 months (IQR: 12.3-56.5). According to the EHS classification for parastomal hernia, there were 47.4% (18/38) type I defects, 10.5% (4/38) type II defects, 28.9% (11/38) type III defects, and 13.2% (5/38) type IV defects. The used mesh was predominantly TiMesh® (76.3%; 29/38), followed by DynaMesh® IPOM (23.7%; 9/38). Patients with recurrence exhibited higher rates of seroma, hematoma, surgical site infection, and one case of early recurrence attributed to mesh retraction. Consequently, postoperative complications emerged as the primary risk factor for hernia recurrence.

CONCLUSION

The sandwich technique demonstrated recurrence rates consistent with those reported in the existing literature.

Laparoscopic parastomal hernia repair: keyhole, Sugarbaker, sandwich, or hybrid technique with 3D mesh? An updated systematic review and meta-analysis

PURPOSE

Parastomal hernia is the most common complication after stoma formation with an incidence that approaches 50% at 2 years postoperatively. In the last decade, different approaches of minimally invasive procedures have been proposed for the treatment of parastomal hernia. Nevertheless, the superiority of one technique over the others remains still unclear. Our objective was to update and systematically analyze current state of research concerning the postoperative outcomes of the four most prevalent minimally invasive techniques.

METHODS

A systematic literature search of three databases (Medline, Scopus, Google Scholar) was undertaken for articles published from January 2015 to November 2022. Fifteen studies from a previous meta-analysis on the topic were included.

RESULTS

Thirty-three studies incorporating 1289 total patients were deemed eligible for inclusion in the final analysis. The keyhole technique was associated with the highest incidence of postoperative complications and recurrences (31.3% and 24.1%, respectively), followed by the Sugarbaker technique (27.6% and 9%, respectively). Operative time was among the lowest in patients operated with the 3D mesh technique, while patients undergoing the keyhole technique experienced the shortest cumulative length of hospital stay (6 days).

CONCLUSION

Each technique demonstrates a unique profile of effectiveness offset by the propensity towards developing postoperative complications. While no conclusive evidence on the optimal technique exist to date, newer minimally invasive techniques show promising results, albeit based on limited data. The future of parastomal hernia repair seems to rely on a highly individualized approach, tailored to the distinctive characteristics of both the hernia and the patient.

Surgical strategies for recurrent parastomal hernia after a primary repair with a Dynamesh® IPST mesh

PURPOSE

To introduce our surgical strategies for recurrent parastomal hernia after a primary repair with a Dynamesh^® IPST mesh.

METHODS

Ten patients who underwent recurrent parastomal hernia repair with previous Dynamesh^® IPST mesh use were analyzed retrospectively. Distinct surgery strategies were applied. Accordingly, we investigated the recurrence rate and postoperative complications in these patients, who were followed for an average of 35.9 months after surgery.

RESULTS

There was no recorded death and no readmission during the 30-day postoperative period. And the lap-re-do Sugarbaker group had no recurrence, whereas the open suture group had one recurrence (16.7%). One patient in the Sugarbaker group developed ileus and recovered conservatively during the follow-up period. There were no other complications, including seroma, mesh infection and bulging, or prolonged postoperative pain.

CONCLUSIONS

We offer two predominant surgery strategies for recurrent parastomal hernia with a previous Dynamesh^® IPST mesh usage, the open suture repair, and the Lap-re-do Sugarbaker repair. Even though the results of the Lap-re-do Sugarbaker repair are satisfactory, we recommend the open suture technique as it is safer in a setting of dense adhesions in recurrent parastomal hernias.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

INTRODUCTION

The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations.

METHODS

We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis.

RESULTS

Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial.

CONCLUSION

A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

Modified Laparoscopic Sugarbaker Repair of Parastomal Hernia With a Totally Extraperitoneal Technique

Purpose: Many patients develop a parastomal hernia within the first 2 years of stoma formation, and even surgical repair is associated with high recurrence rates. An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia; it is unknown whether a totally extraperitoneal technique (TEP) is feasible. Here we describe a laparoscopic TEP approach using a modified Sugarbaker method for the repair of parastomal hernia.

Methods: Seven patients underwent parastomal hernia repair. The retrograde puncture technique was used to create the extrapneumoperitoneum, and the peritoneum was separated with a laparoscopic TEP approach; the mesh was placed using a modified Sugarbaker technique.

Results: All patients had an oncologic etiology for stoma creation. The mean (±SD) size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm². The mean operative time was 195.5 ± 20.7 min and average length of hospital stay after surgery was 4.8 ± 2.1 days. One patient had intraoperative subcutaneous emphysema. The average follow-up time was 8.5 ± 2.7 months; mild pain occurred in 2 patients, 3 experienced seroma formation (with no special treatment required), and 1 had early intestinal obstruction (which was treated with conservative care). There was no hernia recurrence, wound complications, or infections of the surgical site or mesh during follow-up.

Conclusion: A laparoscopic TEP technique is technically challenging but feasible. Modified laparoscopic Sugarbaker repair of a parastomal hernia with the TEP technique is safe and effective, although the recurrence rate and late complications require confirmation in more cases with long-term follow-up.