Surgery in paraostomy hernia

Parastomal hernia- management : 

Parastomal hernia- management Dr John AC Thanakumar MS, MNAMS, FRCS, FRCS, Dip MIS, FIAGES Senior Consultant, Minimal Access, Bariatric and GI Surgery, Global Hospital, Chennai drjact@gmail.com

Slide 2: 

Parastomal hernia is not an uncommon complication after ileostomy or colostomy

Definition : 

Definition Parastomal hernia is an incisional hernia related to an abdominal wall stoma

Stoma Prolapse : 

Stoma Prolapse Stomal Prolapse is defined as eversion of the stoma through the abdominal wall Cochrane database Syst Rev 2007. Guenaga KF, et al

Classification of parastomal Hernia : 

Classification of parastomal Hernia Subcutaneous type Interstitial type Perostomal type Intrastomal type Not clinical SCNA 2008. Leif A Isreaelsson

Incidence : 

Incidence 4% to 48.1% after end colostomy 30.8% after loop colostomy 1% to 39.4% after end ileostomy 1.8% to 28.3% after loop ileostomy Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562-1572.

Risk Factors : 

Risk Factors Obesity Malnutrition Raised intra-abdominal pressure Corticosteroid Increasing age and Cancer recurrence

Early Δ is Vital : 

Early Δ is Vital Prevent Intestinal Obstruction Strangulation Big bulge near the stoma ± Pain

CT Abdomen : 

CT Abdomen Undetectable Anatomy of the hernia Location of fascia defect Abscess or ? Not Space 4 reduction &closure

How do you bring out a stoma? : 

How do you bring out a stoma? Never through the laparotomy wound Construct extra peritoneal vs intra Through rectus M(3%) vs lateral to rectus(22%) Opening not too large - 2.5 cm No need to fix mesentery or bowel to fascia SCNA 2008. Leif A Isreaelsson

Surgery : 

Surgery Surgical repair in 11-70% of parastomal hernia

Option in surgery : 

Option in surgery ✗ Relocate the stoma and fix the hernia Needs laparotomy Hernia at new site 24-86% Hernia at old stoma site Hernia at midline incision Never in the same quadrant

Principles of Mesh Repair : 

Principles of Mesh Repair A. Onlay B. Inlay C. Sublay D. Intra peritoneal onlay mesh- IPOM SCNA 2008

A.Open Onlay : 

A.Open Onlay Easy to reduce hernia Difficult to adhesiolyse Large periwound cavity Wound complications Difficult wound care -Via Midine Difficult in obese Devascularises tissue Recurs in 26% Steele SR, Am J Surg 2003

B.Inlay or interposition : 

B.Inlay or interposition High recurrence of Ventral Hernia Given up

C. Open Sublay (Underlay) : 

C. Open Sublay (Underlay)

Ideal Mesh at present : 

Ideal Mesh at present Two layered mesh ePTFE IPOM Technique Lap vs Open ✗ Prolene mesh Fistula Adhesion Sepsis Seroma ✓

LaPlace’s Law : 

LaPlace’s Law “.. The same forces that cause herniation can be used to prevent recurrences”

LaPlace’s law : 

LaPlace’s law “… the larger the prosthesis, the more efficient the repair.” Kristi Harold, Arizona

D.IPOM – Open Repair : 

D.IPOM – Open Repair Sugarbaker; Peritoneal Approach, Ann Surg, March 1985.

Sugarbaker method : 

Sugarbaker method K Harold.Operative Techniques in Gen Surg 2007

IPOM – Laparoscopic Surgery : 

IPOM – Laparoscopic Surgery Laparoscopic giant paraotomal hernia repair with prosthetic mesh- Pekmerci S, et al – Tech Coloproctol 2002 , 6:187-90 Laparoscopic parastomal hernia repair using a nonslit mesh technique. - Mancini GJ - Surg Endosc - 01-SEP-2007; Multimedia article: laparoscopic repair of parastomal hernia using a porcine dermal collagen (Permacol) implant. - Inan I - Dis Colon Rectum - 01-SEP-2007; 50(9): 1465 (MEDLINE® is the source for the citation and abstract of this record ) Laparoscopic repair of ileal conduit parastomal hernia using the sling technique. - Mirza B - JSLS - 01-APR-2008; 12(2): 173-9

Theater Set Up : 

Theater Set Up

Adhesiolysis : 

Adhesiolysis

Defect size + 5cm beyond : 

Defect size + 5cm beyond

Slide 26: 

No slit mesh Slit mesh

Outcome Lap Parastomal Repair : 

Outcome Lap Parastomal Repair 55 pts 85% completed laparoscopically Days 4 6 enterotomies 2 mesh infections 20 recurrences (37%) in 36 months Hansson, et al, Surg Endosc, 2009 July

Keyhole vs Sugarbaker(Literature review) : 

Keyhole vs Sugarbaker(Literature review)

Lap Parastomal Hernia ( no slit mesh) : 

Lap Parastomal Hernia ( no slit mesh) 6 centers 25 patients All competed lap Morbidity 23% LOS 3.3 days 1 Mesh infection 4% Recurrence Mancini GJ et al Surg Endo, Sept 2007

Lap Repair by Single Surgeon 66 Pts : 

Lap Repair by Single Surgeon 66 Pts 66 patients Two different techniques/2 different meshes 2 meshes overlapped in last 25 out of 66 Recurrence 12% in first 41 pts Recurrence 0% in last 25 pts Dieter Berger, Germany,Dis Colon Rectum Aug 2007

Prophylactic Mesh for Ostomy with no hernia- ? Future : 

Prophylactic Mesh for Ostomy with no hernia- ? Future Prospective RCT under way Use of Acellular Human Dermal Matrix ( Alloderm) to prevent Parastomal Herniation RTA with Alloderm vs no mesh Early results better with prophlactic mesh

Summary : 

Summary Parastomal hernia is a major problem -30% All repairs have significant morbidity Dual mesh is a must Technique may be open or lap -IPOM Need long term RCTs for better evidence

Thank you : 

Thank you