Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial

BACKGROUND

Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days.

METHODS

This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications.

RESULTS

A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days.

CONCLUSION

Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.

Contemporary Outcomes of Elective Parastomal Hernia Repair in Older Adults

Importance

Parastomal hernia is a challenging complication following ostomy creation; however, the incidence and long-term outcomes after elective parastomal hernia repair are poorly characterized.

Objective

To describe the incidence and long-term outcomes after elective parastomal hernia repair.

Design, Setting, and Participants

Using 100% Medicare claims, a retrospective cohort study of adult patients who underwent elective parastomal hernia repair between January 1, 2007, and December 31, 2015, was performed. Logistic regression and Cox proportional hazards models were used to evaluate mortality, complications, readmission, and reoperation after surgery. Analysis took place between February and May 2022.

Exposures

Parastomal hernia repair without ostomy resiting, parastomal hernia repair with ostomy resiting, and parastomal hernia repair with ostomy reversal.

Main Outcomes and Measures

Mortality, complications, and readmission within 30 days of surgery and reoperation for recurrence (parastomal or incisional hernia repair) up to 5 years after surgery.

Results

A total of 17 625 patients underwent elective parastomal hernia repair (mean [SD] age, 73.3 [9.1] years; 10 059 female individuals [57.1%]). Overall, 7315 patients (41.5%) underwent parastomal hernia repair without ostomy resiting, 2744 (15.6%) underwent parastomal hernia repair with ostomy resiting, and 7566 (42.9%) underwent parastomal hernia repair with ostomy reversal. In the 30 days after surgery, 676 patients (3.8%) died, 7088 (40.2%) had a complication, and 1740 (9.9%) were readmitted. The overall adjusted 5-year cumulative incidence of reoperation was 21.1% and was highest for patients who underwent parastomal hernia repair with ostomy resiting (25.3% [95% CI, 25.2%-25.4%]) compared with patients who underwent parastomal hernia repair with ostomy reversal (18.8% [95% CI, 18.7%-18.8%]). Among patients whose ostomy was not reversed, the hazard of repeat parastomal hernia repair was the same for patients whose ostomy was resited vs those whose ostomy was not resited (adjusted hazard ratio, 0.93 [95% CI, 0.81-1.06]).

Conclusions and Relevance

In this study, more than 1 in 5 patients underwent another parastomal or incisional hernia repair within 5 years of surgery. Although this was lowest for patients who underwent ostomy reversal at their index operation, ostomy resiting was not superior to local repair. Understanding the long-term outcomes of this common elective operation may help inform decision-making between patients and surgeons regarding appropriate operative approach and timing of surgery.

Biologic vs Synthetic Mesh for Parastomal Hernia Repair: Post Hoc Analysis of a Multicenter Randomized Controlled Trial

BACKGROUND

Parastomal hernias are often repaired with mesh to reduce recurrences, but the presence of an ostomy increases the wound class from clean to clean-contaminated/contaminated and makes the choice of mesh more controversial than in a strictly clean case. We aimed to compare the outcomes of biologic and synthetic mesh for parastomal hernia repair.

STUDY DESIGN

This is a post hoc analysis of parastomal hernia repairs in a randomized trial comparing biologic and synthetic mesh in contaminated ventral hernia repairs. Outcomes included rates of surgical site occurrences requiring procedural intervention (SSOPI), reoperations, stoma/mesh-related adverse events, parastomal hernia recurrence rates (clinical, patient-reported, and radiographic) at 2 years, quality of life (EQ-5D, EQ-5D Visual Analog Scale, and Hernia-Related Quality of Life Survey), and hospital costs up to 30 days.

RESULTS

A total of 108 patients underwent parastomal hernia repair (57 biologic (53%) and 51 synthetic (47%)). Demographic and hernia characteristics were similar between the two groups. No significant differences in SSOPI rates or reoperations were observed between mesh types. Four mesh erosions into an ostomy requiring reoperations (2 biologic vs 2 synthetic) occurred. At 2 years, parastomal hernia recurrence rates were similar for biologic and synthetic mesh (17 (29.8%) vs 13 (25.5%), respectively; P=.77). Overall and hernia-related quality of life improved from baseline and were similar between the two groups at 2 years. Median total hospital cost and median mesh cost were higher for biologic compared to synthetic mesh.

CONCLUSION

Biologic and synthetic mesh have similar wound morbidity, reoperations, 2-year hernia recurrence rates, and quality of life in parastomal hernia repairs. Cost should be considered in mesh choice for parastomal hernia repairs.

Parastomal Hernia Repair Outcomes: A Nine-Year Experience

Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/ absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board–approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) versus III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH vs LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.

Recovery after laparoscopic parastomal hernia repair

BACKGROUND

The perioperative care and postoperative period after laparoscopic hernia repair have not been well described. The aim of this study was to describe the postoperative course after laparoscopic parastomal hernia repair.

METHODS

This was a prospective cohort study including consecutive patients undergoing laparoscopic parastomal hernia repair. The outcomes of interest were patient-reported pain, nausea and fatigue, time to stoma function, length of stay (LOS), use of transversus abdominis plane (TAP) block and epidural analgesia, the cumulative dose of morphine equivalent analgesics during the first 5 postoperative days, and postoperative complications.

RESULTS

Forty patients were included, 20% had ileostomy and 80% colostomy. The mesh was placed according to Sugarbaker (87.5%) and keyhole (12.5%) technique. Twenty-two patients (55%) required peripheral nervous blockades postoperatively. The median number of days to stoma function was 3 days (range 2-3.8). The mean cumulative dose of morphine equivalent analgesics was 21.9 mg on the day of surgery, 27.8 mg on the first postoperative day (POD1), 23.9 on POD2, 17.3 mg on POD3, 15.3 mg on POD4, 8.9 mg on POD5, and 115.2 mg in total. The median LOS was 4 days (range 3-6). The incidence of postoperative complications was 25%.

CONCLUSION

Laparoscopic parastomal hernia repair carried a high risk of complications. Further, analgesic treatment after surgery was insufficient, with high opioid requirements postoperatively, and more than half of the patients required peripheral nervous blockades, indicating that postoperative pain is a major issue in this patient group. Improved postoperative care for these patients is required.

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

BACKGROUND

Nearly 50% of patients with an ostomy will develop a parastomal hernia (PSH). Its repair remains a surgical challenge. Both laparoscopic "modified Sugarbaker" (SB) and Keyhole (KH) repair are currently in use, frequently with unsatisfactory results.''Sandwich Repair'' (SR) may be an alternative to reduce recurrence rates. We present the change of our technique from KH to SR.

METHODS

We collected data from all consecutive laparoscopic PSH repairs at our institution from 2004 until now (from 2004 to 2013 treated with KH, from 2014 with SR) and compared the results of the two groups. Primary endpoint was recurrence rate at 1 year. Secondary outcomes were operative time, PO length of hospital stay (LOS), and short and long-term complications.

RESULTS

13 patients underwent SR. Main changes in surgical technique concerned primary defect closure, no stay sutures, use of glue for first mesh fixation, and partial lateral covering of the underlying mesh with a peritoneal flap. Early postoperative course after SR was uneventful and no recurrence at 1 year was recorded. In the KH group (19 patients), short-term complications occurred in two cases (10%), with one parietal hematoma and one case of intensive pain; we had four recurrences at 1 year (21%). LOS was shorter in the SR group (mean 4 days vs 6, p = 0.004). The KH group had 2 (10%) occurrences of chronic seroma and one bowel perforation (5%), while the SR group had one (8%) occurrence of chronic pain. Median follow-up was 26 months (range 13-78) for the SR group and 47 months (12-105) for the KH group.

CONCLUSION

SR is safe and effective in expert hands and provides promising preliminary results.

Laparoscopic parastomal hernia repair delays recurrence relative to open repair

BACKGROUND

Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair.

METHODS

An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair.

RESULTS

Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively).

CONCLUSIONS

Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.

What's New in the Management of Incarcerated Hernia

Management of incarcerated hernias is a common issue facing general surgeons across the USA. When hernias are not able to be reduced, surgeons must make decisions in a short time frame with limited options for patient optimization. In this article, we review assessment and management options for incarcerated ventral and inguinal hernias.

An Evaluation of Fascial Closure Techniques in Open Ventral Hernia Repair: Practice Patterns and Short-Term Outcomes

The best method for fascial closure during hernia repair remains unknown. This study evaluates the impact of fascial closure techniques on short-term outcomes. All patients undergoing open ventral hernia repair were queried using the Americas Hernia Society Quality Collaborative database. Analysis was stratified by suture type (absorbable and permanent) and technique (figure-of-eight, running, and interrupted). Outcome measures included SSI, surgical site occurrence (SSO), SSO requiring intervention, recurrence rate, and quality of life. Descriptive statistics and logistic regression were used. The study included 6544 patients. Two-thirds of surgeons closed fascia during ventral hernia repair with absorbable suture and one-third with permanent suture. In the absorbable group, 17 per cent used figure-of-eight, 46 per cent running, and 4 per cent interrupted suture. In the permanent group, 13 per cent used figure-of-eight, 8 per cent running, and 11 per cent interrupted suture. There was no significant association between SSO and closure technique ( P = 0.2). However, SSO and suture type were significant ( P < 0.001) with the odds of SSO for closure with absorbable suture being 62 per cent higher than the odds of permanent. Fascial closure technique and suture type had no significant association ( P > 0.5) with SSI, SSO requiring intervention, hernia recurrence rate, or HerQLes or NIH PROMIS 3a scores at 30 days or 6 months. Fascial closure technique and suture material do not have a major impact on outcomes in ventral hernia repair. Despite a significantly higher rate of SSO for absorbable sutures than permanent, this did not increase the rate of interventions.

Professional fee payments by specialty for inpatient open ventral hernia repair: who gets paid for treating comorbidities and complications?

BACKGROUND

The purpose of this study was to determine perioperative professional fee payments to providers from different specialties for the care of patients undergoing inpatient open ventral hernia repair (VHR).

METHODS

Perioperative data of patients undergoing VHR at a single center over 3 years were selected from our NSQIP database. 180-day follow-up data were obtained via retrospective review of records and phone calls to patients. Professional fee payments (PFPs) to all providers were obtained from our physician billing system for the VHR hospitalization, the 180 days prior to operation (180Prior) and the 180 days post-discharge (180Post).

RESULTS

PFPs for 283 cases were analyzed. Average total 360-day PFPs per patient were $3409 ± SD 3294, with 14.5% ($493 ± 1546) for services in the 180Preop period, 72.5% ($2473 ± 1881) for the VHR hospitalization, and 13.0% ($443 ± 1097) in the 180Postop period. The surgical service received 62% of PFPs followed by anesthesia (18%), medical specialties (9%), radiology (6%), and all other provider services (5%). Medical specialties received increased PFPs for care of patients with COPD and HCT < 38% ($90 and $521, respectively) and for the pulmonary complications ($2471) and sepsis ($2714) that correlated with those patient comorbidities; surgeons did not. Operative duration, mesh size, and separation of components were associated with increased surgeon PFPs (p < .05). At 6 months, wound complications were associated with increased surgeon and radiology payments (p < .01).

CONCLUSIONS

Management of acute comorbid conditions and the associated higher postoperative morbidity is not reimbursed to the surgeon under the 90-day global fee. These represent opportunity costs of care that pressure busy surgeons to select against these patients or to delegate more management to their medical specialty colleagues, thereby increasing total system costs. A comorbid risk adjustment of procedural reimbursement is warranted. In negotiating bundled payments, surgeon groups should keep in mind that surgeon reimbursement, unlike medical specialty and hospital reimbursement, have been bundled since the 1990s.