Parastomy Hernia Laparoscopy

Parastomy Hernia Laparoscopy Approach like a Tie Knot

CÉSAR GUERREIRO DE CARVALHO (of American College Surgeon and Member of American Hernia Society)
CARLOS EDUARDO PEREIRA VALLE (Coloproctologista H. SESI)
PAULO CÉSAR CASTRO (Coloproctologista H. Pedro Ernesto; Stoff Clínico Dr. César Guerreiro)
THIAGO BORGES FRADE (Staff da Casa de Saúde Sta. Lucia S.A. )

 

A very usual and almost unavoidable complication, the parastomy hernia, that occurs in after surgery and that immediately improves the problems enforced by the ostomy. The treatment always relegates to a second level and brings great frustration for the failure and perturbation imposed to the patient. We introduce a different and simple alternative approach to this problem with the smallest inconvenience as possible to solve the trouble. We use for the treatment a prosthetic repair of the defect with ePTFE mesh, performed laparoscopically, intra-peritoneal like a tie.

parastomy, hernia; Laparoscopy; Surgery


Having a hernia around a colostomy is so common that it can be considerate unavoidable [1]. At physical examination this pathology shows itself like a discreet camber during Valsalva’s maneuver or introduce itself as a voluminous bulge showing the colostomy on the top.

Many articles demonstrate a result that’s goes from 5% up to 100% of this pathology incidence in patients with stomas [2,3,4,5]. Although a lot of this cases are well tolerated and can be treated by traditional procedure like abdominal brace or bell. However, approximately 30% of these hernias have to be surgically repaired. [6,7,8,9] Bleeding, pain, obstruction, abdominal mass, aesthetic appearance, difficulty to use colostomy pouch, leaking and skin injures are some of the indications to surgery treatment.

The parastomy hernia’s physiopathology should be caused by an abdominal failure created by the colostomy bowel.

A correct preparation of the ostomy is proposed to avoid a hernia, making a separated access and a tunnel to a satisfactory accommodation to the ostomy. These cares lead to a lower incidence of the hernias, especially when we make it through the abdominal musculature, [10,11] although it doesn’t help when we have lower incidence of peri ileostomy hernias made by the same way. However, we find a clear prevalence of the hernias in stomas located laterally to the abdominal straight muscle, as in the iliac colostomies. [10,11]

Another factor in hernia’s genesis is the abdominal innervation and abdominal muscle activity [12]. When we have a denervated abdominal wall, we improve the chances to have hernia because of the musculature’s inability to contract around the stoma during some situations that increase the intra abdominal pressure. So we have to pay attention to previous abdominal incisions (Kocher, transverse), old colostomy, paraplegias and sclerosis. The electromyography can help us on these cases.

Others factors can be involved like: obesity, sedentary, CPOD, ascite, malnutrition, steroids and advanced age. [10,11]

The risk of peristomal hernia enlarges as time goes by; 48% of the hernias appearance at the first year of the surgery and after two years should reach 36 to 100%. [10,11]

The permanent colostomy develops hernias (58%) more often than permanent ileostomy (28%) or urostomy (5%-8%). The loop colostomy is less frequent than terminal colostomies. [10,11]

We can classify the parastomy hernias in: truly peristomal hernia; intra-ostomy hernia (it can be associated with prolapse); pseudo hernia with subcutaneous prolapse and fascia hole intact; pseudo hernia by wall weakness without any fascia defectors. [10,11]

Surgery alternatives for the treatment of the parastomy hernias establish a way replaced ostomy, which doesn’t exclude the possibility of a new hernia at the new ostomy, or the hernia correction at the current place which is better, because it will be more acceptable by the patient. [13]

We don’t find in the literature an agreement about what is the best surgery procedure. Thorlakson [14] recommends the repair using non absorbable wire, not changing the place of the ostomy. In another away, Golingher [1] recommends the reallocation of the stoma and closing of the aponeurotic defect. The repairs of larger hernias can be made using a mesh superposing deformity and passing the intestinal tract through the mesh, [15,16] some surgeons using a second way to avoid contamination. [17,18]

With the advances in laparoscopic techniques to correct other hernias types (Incisional and ventral) we have an improvement in use of these techniques for parastomy hernias. [13,19,20,21]

So, we introduce a new surgery alternative to correct parastomy hernias, using an expanded polytetrafluorethylene mesh (ePTFE – GORE-TEX™ Biomaterial; W. L. Gore & Associates, Flagstaff, AZ) at intra-peritoneal repair, performed laparoscopically and positioned like a knot of necktie.

We demonstrate a surgery correction of a large peristomal hernia in a 54 years old male patient who has definitive terminal sigmoid ostomy caused by inferior rectal carcinoma, treated by abdominoperineal resection 7 years ago. (Figure 1)

foto1
Figure 1 – parastomy hernia view with back lights

The patient was submitted to a laparoscopic surgery with general anesthesia and after the pneumoperitoneum confection the trocarters were placed like we exposed at figure 2.

foto2Figure 2 – Trocaters positions

We made the cavity inventory, followed by adhesiolysis and reduction of the hernia contents that consent us to see the aponeurotic defect size and the ostomy location.

In a second step we confectioned the mesh like the techniques propose and we show at figure 3,4,5 and 6

foto6Figure 3 – Prepared mesh
foto3Figure 4 – Positioning the mesh
foto4Figure 5 – Adjust the mesh foto5

Figure 6 – Adjust the mesh like a tie knot

After the introduction of the mesh in the abdominal cavity, it was positioned using anchorages stitches by Prolene 0-0 (Ethicon™) fixing the mesh to abdominal wall; them both edges were positioned crossing, one after the other, like a tie knot seeking to restrict the hole but without strangle. So the distance between sigmoid and mesh was closed with simple stitches at bowel and the mesh remains was fixed by stapler Protac (Auto Suture™). (Figure 7)

foto7Figure 7 – Final aspect

The patient eats at same day and checks out from hospital the next day.

The incidence of parastomy hernia is a very frequent pathology and many times is followed by complications like pain, intestinal obstruction, skin injure, aesthetic alterations and difficulty to use colostomy pouch. [22,23,24]

The primary repair of these hernias ends in more than 50% of recurrence, which improves a strong opinion of those who are propitious to replace the colostomy. [25] Even though this alternative becomes awkward to patient who already had become used to manuscript its colostomy pouch’s, and it’s still possible to have another hernia at the new place. [1]

Abdu [15] and Rosin & Bonardi [16] describe the use of the polyethylene mesh around the colon to repair these hernias. Although their operated patients didn’t have infections or recurrence, we think it’s a risk to have a synthetic prosthesis near a potentially contaminated area.

Sugarbaker [17] developed another technique for the repair of these hernias in 1985, using a laparotomic incision for the correction of the aponeurotic defect, preventing itself thus, the existing contamination in the neighborhoods of the ostomy. The derived bowel does not need to be changed of place and the mesh is located in a way to cover the hernia’s orifice and placing laterally the colon for under the mesh. In its initial series of seven patients, six of them having recurrent hernia and one with primary hernia, none presented infection and no recurrence was observed in the four years of accompaniment. However this technique demands great incisions which can be complicated for those patients who carry multiple surgeries or that possess morbidities associated, beyond the biggest surgical trauma that an operation of this size imposes.

The development of laparoscopic surgical techniques for the treatment of ventral and incisional hernias made possible the development of laparoscopic procedures for the correction of the peristomal hernias, using  the same principles just discovered.

Porcheron et al. [19] describe the use of ePTFE mesh in laparoscopic technique, placed at pre-peritoneal area and fixed with staples. The hernia gap is closed using double suture and the mesh is used as reinforce and is recovered by peritoneal tissue. No cuts are made in the mesh to avoid strangulation. The patient was discharged from hospital at fourth day after surgery and hasn’t have recurrence one year past.

Voitk [21] describe a laparoscopic technique similar of Sugarbaker’s tactics, using a polypropylene mesh that cover hernia hole disposed in an intra-peritoneal way. No cut is done in the mesh that is fixed by unabsorbed suture covering the colon, and remain of the mesh are fixed by staples. No complications were reported after 12 months and  the time of postoperative permanence varied from two to nine days.

Bickel et al [20] mention one case of parastomy hernia treated by laparoscopic method, using polypropylene mesh prepared to correct the gap with a circle cut in the center of the mesh, positioned in an intra-peritoneal way fixing with staples. The lateral mesh’s edge was fixed closer to the colon with staples and the other edge was fixed at serosa. This technique doesn’t calculate the risk of adherences and perforations related on to the polypropylene mesh.

The laparoscopic approach allows us the opportunity to stratify patient who has cancer, like in the mentioned case, it allows adhesiolysis, preventing future complications and in some cases treating the cause of a great discomfort.

The mesh intra-peritoneal apply reduce dissection area and their consequences like hematoma, seroma, and infection. The use of correct material, like ePTFE mesh, reduces risk of adherences and fistulas.

A difficult that we see about mesh shape, is because we have to close hernia’s hole, without strangle colon, and to avoid these complications we made a central hole with a larger fissure in the base of mesh. That modification allows us a perfect adaptation to different colostomy and hernia diameters, by crossing the edges. At first we fix the body of mesh that covers the hernia gap and after we adjust central mesh’s orifice, that will accommodate colostomy, crossing terminal edges.

Comparing all the results, in surgical repair of parastomy hernia, our technique reduces the period of hospitalization and improves patient’s adaptation to postoperative period. On the other hand, we have one of the larger follow-up times without increase complications as you can see bellows.

Reference

Patients (n)

Kind of mesh

Mesh’s localization

Hospitalization (days)

Follow-up (months)

Porcheron et al. (1998)

01

ePTFE

Pre- peritoneal

04

12

Bickel et al. (1999)

01

Polypropylene

Intra-peritoneal

06

12

Voitk (2000)

04

Polypropylene

Intra-peritoneal

02 (3pc) e 09 (1pc)

N/A

Kozlowski et al (2001)

04

ePTFE

Intra-peritoneal

3,8

2-33

LeBlanc et al (2002)

03

ePTFE

Intra-peritoneal

01

3-11

Berger (2002)

15

ePTFE

Intra-peritoneal

N/A

3-12

Carvalho et al (2005)

08

DM

Intra-peritoneal

01

2 to 16

 

The parastomy hernia’s appearance, many times, imposes to the patients a hard charge, adding difficult to accept ostomy and to their lives.

The surgeries alternatives, already acclaim, reveal some times, factors that contra-indicates its selves.

We present you a new alternative to these hernias’s treatment – laparoscopic peristomal hernia plastic; using a mesh like a tie knot.

Our method is feasible, should follow laparoscopy’s principles and depends on the surgeon’s skill.

The techniques elaborated by our team aims to cure hernia without strangle ostomy. It does allow perfect correction of different colostomy diameters using the interposition of the mesh’s edges and due to the lower surgery injure we have a fast recuperation, of the patient, discharging him from hospital 24 hours after the surgery, without risk obstruction.

 

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Endereço para correspondência

Dr. César Guerreiro

Av. N.S. de Copacabana,

647 sala 509 22050-000

Rio de Janeiro- RJ

E-mail: cesarguerreiro@terra.com.br

2017-09-05T11:07:49+00:00