Modified technique of extraperitoneal colostomy without incision of the posterior rectus sheath

Modified Approach for Extraperitoneal Colostomy Creation in Laparoscopic Abdominoperineal Resection

BACKGROUND

Parastomal hernia is a major long-term complication after abdominoperineal resection. Extraperitoneal colostomy has been proposed as an effective step for parastomal hernia prevention, but it has not been widely used as it is technically demanding and time-consuming. We proposed a modified approach for extraperitoneal colostomy creation by entering the extraperitoneal space through the arcuate line of the posterior rectus sheath.

OBJECTIVE

To evaluate the safety, difficulty, and efficacy of long-term parastomal hernia prevention of the modified approach for extraperitoneal colostomy creation compared with the conventional transperitoneal colostomy approach.

DESIGN

This was a retrospective evaluation of a surgical and video database.

SETTINGS

This was a single-institution retrospective study.

PATIENTS

Clinical data of 74 patients who underwent laparoscopic abdominoperineal resection surgery from January 2019 to January 2020 in the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively reviewed.

MAIN OUTCOME MEASURES

Baseline characteristics, time required for colostomy creation (from skin incision to colostomy maturation), perioperative complications, and long-term colostomy-related complications were compared.

RESULTS

Baseline characteristics did not differ between the 2 approaches. The BMI level ranged from 19.5 to 29.4 for patients undergoing extraperitoneal approach. Time required for colostomy creation median [interquartile range], (22 [21-25] minutes for extraperitoneal vs 23 [21-25] minutes for transperitoneal, p = 0.861) were comparable between the 2 approaches. The cumulative incidence of parastomal hernia was significantly greater with transperitoneal colostomy than extraperitoneal colostomy at 2 and 3 years postoperatively (16.2% vs 0%, p = 0.025, and 21.6% vs 0%, p = 0.005). The remaining perioperative complications and long-term colostomy-related complications did not differ between the 2 approaches.

LIMITATIONS

This study is limited by its retrospective design and small sample size.

CONCLUSIONS

The modified approach for extraperitoneal colostomy creation is safe, technically simple, and effective for long-term parastomal hernia prevention in patients with a BMI of 19.5 to 29.4.

A technique for laparoscopic extraperitoneal colostomy with an intact posterior sheath of rectus

Regardless of the advances in surgical techniques, parastomal hernia is still an inevitable complication for many patients with low rectal cancer undergoing abdominal perineal resection (APR). Extraperitoneal colostomy (EPC) seems to be a effective method to reduce the risk of parastomal hernia. We propose a new approach to simplify and standardize laparoscopic EPC to make this operation easy to perform. We used the technique of laparoscopic TEP groin hernia repair to produce an extraperitoneal tunnel, which can not only facilitate precise visualization of the extraperitoneal tunnel but also utilize the intact posterior rectus abdominis sheath as biologic materials to maintain soft-tissue augmentation, with a satisfactory result. With laparoscopy, we can create adequate space without insufficient dissection of the extraperitoneal tunnel while avoiding damage to the retrorectus sheath. At the time of writing, we had performed this method in four patients, without any complications. This technique is effective at preventing parastomal hernia without extra costs.