Parastomal Hernia Repair: a Single Center Experience

Background/Objectives:

Despite multiple options for operative repair of parastomal hernia, results are frequently disappointing. We review our experience with parastomal hernia repair.

Methods:

A retrospective chart review was performed on all patients with parastomal hernia who underwent LAP or open repair at our institution between 1999 and 2006. Information collected included demographics, indication for stoma creation, operative time, length of stay, postoperative complications, and recurrence.

Results:

Twenty-five patients who underwent laparoscopic or open parastomal hernia repair were identified. Laparoscopic repair was attempted on 12 patients and successfully completed on 11. Thirteen patients underwent open repair. Operative time was 172±10.0 minutes for laparoscopic and 137±19.1 minutes for open cases (P=0.14). Lengths of stay were 3.1±0.4 days (laparoscopic) and 5.1±0.8 days (open), P=0.05. Immediate postoperative complications occurred in 4 laparoscopic patients (33.3%) and 2 open patients (15.4%), P=0.38. Parastomal hernia recurred in 4 laparoscopic patients (33.3%) and 7 open patients (53.8%) after 13.9±4.5 months and 21.4±4.3 months, respectively, P=0.43.

Conclusion:

Laparoscopic modified Sugarbaker technique in the repair of parastomal hernia affords an alternative to open repair for treating parastomal hernia.     

Single-Port Laparoscopic Parastomal Hernia Repair with Modified Sugarbaker Technique

Introduction:

Laparoscopic parastomal hernia repair with modified Sugarbaker technique has become increasingly the operation of choice because of its low recurrence rates. This study aimed to assess feasibility, safety, and efficiency of performing the same operation with single-incision laparoscopic surgery.

Materials and Methods:

All patients referred from March 2010 to February 2013 were considered for single-port laparoscopic repair with modified Sugarbaker technique. A SILS port (Covidien, Norwalk, Connecticut, USA) was used together with conventional straight dissecting instruments and a 5.5- mm/52-cm/30° laparoscope. Important technical aspects include modified dissection techniques, namely, “inline” and “chopsticks” to overcome loss of triangulation, insertion of a urinary catheter into an ostomy for ostomy limb identification, safe adhesiolysis by avoiding electocautery, saline -jet dissection to demarcate tissue planes, dissection of an entire laparotomy scar to expose incidental incisional hernias, adequate mobilization of an ostomy limb for lateralization, and wide overlapping of defect with antiadhesive mesh.

Results:

Of 6 patients, 5 underwent single-port laparoscopic repair, and 1 (whose body mass index [BMI] of 39.4 kg/m² did not permit SILS port placement) underwent multiport repair. Mean defect size was 10 cm, and mean mesh size was 660 cm² with 4 patients having incidental incisional hernias repaired by the same mesh. Mean operation time was 270 minutes, and mean hospital stay was 4 days. Appliance malfunction ceased immediately, and pain associated with parastomal hernia disappeared. There was no recurrence with a follow-up of 2 to 36 months.

Conclusion:

Compared with multiport repair, single-port laparoscopic parastomal repair with modified Sugarbaker technique is safe and efficient, and it may eventually become the standard of care.     

腹腔镜造口旁疝修补术13例报告

目的探讨采用腹腔镜钥匙孔手术行造口旁疝修补术的可行性。方法回顾性分析2007年11月～2011年10月采用钥匙孔技术及Proceed补片完成的13例腹腔镜造口旁疝修补术的临床资料。2例回肠代膀胱造瘘,11例左下腹永久性乙状结肠造瘘,其中1例为造口旁疝修补术后复发。术中游离疝周粘连后,将补片适当修剪,中间留圆孔,置于疝囊下方,用5mm螺旋钉枪固定于腹壁。结果所有患者均顺利完成手术。术中并发症2例：横结肠系膜血管损伤1例,造瘘肠管损伤1例;术后并发症3例：切口感染1例,血清肿2例。术后随访5-52个月,平均26个月,1例复发,1例死于肺部感染。结论采用腹腔镜钥匙孔手术及Proceed补片行腹腔镜造口旁疝修补术是安全可行的,临床疗效较为满意,在降低造口旁疝修补术后补片相关并发症发生率和复发率方面具有一定的意义。     

Single-Port Parastomal Hernia Repair by Using 3-D Textile Implants

Background:

Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall.

Methods:

We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications.

Results:

From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively.

Conclusion:

We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.     

改良完全腹膜外腹腔镜疝修补术31例报告

目的评价改良的完全腹膜外腹腔镜疝修补(totally extraperitoneal laparoscopic hernia repair,TEP)手术方法的可行性和安全性。方法2007年1月~8月,在全麻下行改良TEP31例。用一次性吸引器头的塑料外套管对手术区域的腹膜前间隙进行初步分离,再将国产单腔气囊导管小心置入腹膜外间隙,充气扩张建立腹膜外间隙。术中不固定补片。结果手术全部成功,手术时间(69.8±21.8)min,术中出血量(7.6±4.2)ml,术后住院时间(2.6±1.3)d。术中腹膜破裂5例,术后阴囊积液2例,无其他手术并发症。31例随访1~7个月,(4.2±2.4)月,未见复发及腹股沟区慢性疼痛等并发症。结论改良TEP是一种安全可行的无张力疝修补技术,腹股沟区慢性疼痛症状少。     

Single-Incision Laparoscopic Repair of Spigelian Hernia

Introduction:Spigelian hernias represent only 1% to 2% of all abdominal wall hernias. The treatment, however, remains controversial but depends on institutional expertise. This case series reports the first experience with single-incision laparoscopic totally extraperitoneal (SILTEP) repair of Spigelian hernias with telescopic extraperitoneal dissection in combination with inguinal hernia repair.Methods:From February 2013 to April 2014, all patients referred with inguinal or Spigelian hernias, without histories of extraperitoneal intervention, underwent SILTEP repair with telescopic extraperitoneal dissection. A single-port device, 5.5 mm/52 cm/30° angled laparoscope, and conventional straight dissecting instruments were used for all cases. Extraperitoneal dissection was performed under direct vision with preservation of preperitoneal fascia overlying retroperitoneal nerves. Inguinal herniorrhaphy was performed with lightweight mesh that covered low-lying Spigelian defects. High-lying Spigelian defects were repaired with additional mesh.Results:There were 131 patients with 186 (92 direct) inguinal hernias and 7 patients with 8 Spigelian hernias (6 incidental, including 1 bilateral and 2 preoperatively diagnosed), with a mean age of 51.3 years and a mean body mass index of 25.1 kg/m². An additional piece of mesh was used for 3 hernias. All Spigelian hernias were associated with direct inguinal hernias, and 8 combined inguinal and Spigelian hernias were successfully repaired with SILTEP repair with telescopic extraperitoneal dissection as day cases. There were no clinical recurrences during a mean follow-up period of 6 months (range, 1–15 months).Conclusions:Combined Spigelian and inguinal hernias can be successfully treated with SILTEP herniorrhaphy with telescopic extraperitoneal dissection. The high incidence of Spigelian hernias associated with direct inguinal hernias suggests a high index of suspicion for Spigelian hernias during laparoscopic inguinal herniorrhaphy.     

Laparoscopic Repair of Left Lumbar Hernia After Laparoscopic Left Nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.     

经脐入路常规器械腹腔镜经腹腹膜前腹股沟疝修补术

目的探讨使用常规器械行经脐腹腔镜(transumbilical endoscopic surgery,TUES)经腹腹膜前腹股沟疝修补(transabdominal preperitoneal repair,TAPP)的安全性和应用价值。方法回顾分析2018年7月~2019年3月使用常规器械行TUES-TAPP 20例资料。结果20例手术均获成功,无需辅助孔。手术时间45~80(60.7±10.9)min,术中出血<10 ml。术后6 h恢复半流质饮食及下床活动。术后血清肿2例。术后第1天疼痛视觉模拟评分(Visual Analogue Scale,VAS)0~2(0.7±0.8)分,术后住院2~6(3.7±1.0)d。术后随访1~6个月,平均5.2月,无腹股沟疝复发,切口瘢痕隐蔽。结论使用常规器械可以安全完成TUES-TAPP,而且瘢痕隐蔽。     

Long-Term Durability and Comfort of Laparoscopic Ventral Hernia Repair

Background:

Repair of ventral hernias, including primary ventral hernias and incisional ventral hernias, is performed in the United States 90,000 times per year. Open or traditional ventral hernia repairs involve the significant morbidity and expense of a laparotomy and a significant risk of recurrent herniation. Laparoscopic ventral hernia repair (LVHR) may offer a less-invasive alternative with shorter length of hospital stay, fewer cardiopulmonary complications, and low recurrence rates.

Methods:

225 patients underwent laparoscopic ventral hernia repairs in which carboxymethylcellulose-sodium hyaluronate coating (Sepramesh, Davol, Providence, RI) was used primarily. All cases were included prospectively from the study period of 2002 through 2009. Patient characteristics were recorded, and follow-up analysis was performed over a period of 42 mo following surgery. Recurrence, reoperations, and all complications were recorded. Mesh awareness and mesh-related pain were assessed using the hernia-specific Carolinas Comfort Scale (CCS) instrument, completed by 72 patients.

Results:

Over 42 mo of follow-up, 2 ventral hernias have recurred, and no long-term bowel erosion or fistulization has occurred. Little or no mesh-related symptoms were reported, and mean scores for mesh awareness and mesh pain were 3.6 and 3.2, respectively, on a scale from 0–40 (lower scores signify less pain or awareness). Two serious early complications occurred related to intestinal ileus and metal tacks producing intestinal perforation, and this led to a change in the tacking devices used.

Conclusions:

LVHR with carboxymethylcellulose-sodium hyaluronate coating (Sepramesh) is safe and effective. Complications are rare, the repair is durable, and long-term results are good with rare recurrences, low awareness of mesh, and little pain. Technical lessons include use of at least one transfascial suture and the avoidance of metal tacks for fixation.     

Parastomal hernia repair using the lateral approach

OBJECTIVE: To review the results of repairing a parastomal hernia after ileal conduit formation, using the lateral approach. PATIENTS AND METHODS: We retrospectively assessed 18 patients (9%) who developed a parastomal hernia, from 211 who had an ileal conduit created between 1982 and 2001; 15 had a surgical repair using a lateral incision. RESULTS: All 15 patients resumed a normal diet 1 day after surgery; the median (range) hospital stay was 4 (2-14) days. In two patients with a large hernia and difficult repair the stomas became ischaemic and required refashioning. Only one of these two patients required complete conduit replacement. The median (range) follow-up was 15 (1-72) months. A recurrence of the hernia was recorded in one grossly overweight patient. CONCLUSION: The lateral approach obviates the need for laparotomy and stomal relocation, and enhances a quick return of bowel function and early recovery. However, extra care is needed in managing the very large and difficult hernia, to avoid compromising the ileal conduit. The success and complication rates of the current series are within acceptable limits and this technique can be included in the options for managing parastomal hernia.     

Evaluation of the Rebound Hernia Repair Device for Laparoscopic Hernia Repair

Background:

The characteristics of the ideal type of mesh are still being debated. Mesh shrinkage and fixation have been associated with complications. Avoiding shrinkage and fixation would improve hernia recurrence rates and complications. To our knowledge, this is the first study of a device with a self-expanding frame for laparoscopic hernia repair.

Methods:

Six Rebound Hernia Repair Devices were placed laparoscopically in pigs. This device is a condensed polypropylene, super-thin, lightweight, macro-porous mesh with a self-expanding Nitinol frame. The devices were assessed for adhesions, shrinkage, and histological examination. Laboratory and radiologic evaluations were also performed.

Results:

The handling properties of the devices facilitated their laparoscopic placement. They were easily identified with simple x-rays. The mesh was firmly integrated within the surrounding tissue. One device was associated with 3 small adhesions. The other 5 HRDs had no adhesions. We noted no shrinkage or folding. All devices preserved their original size and shape.

Conclusions:

At this evaluation stage, we found that the Rebound Hernia Repair Device may serve for laparoscopic hernia repair and has favorable handling properties. It prevents folding and shrinkage of the mesh. It may eliminate the need for fixation, thus preventing chronic pain. The Nitinol frame also allowed radiologic evaluation for gross movement. Further studies will be needed to evaluate its clinical application.     

Laparoscopic Incisional Hernia Repair in Liver Transplant and Other Immunosuppressed Patients

We report the early results of laparoscopic incisional hernia repair in a small group of immunosuppressed patients and compare these results with a cohort of patients with open repair. We describe a modification used to secure the cephalad portion of the Gore-Tex mesh in high epigastric incisional hernias often encountered after liver transplantation. Data were gathered retrospectively for all incisional hernia repairs by our group from March 1996 to January 2001. Twelve of 13 attempted patients had successful completion of their laparoscopic hernia repairs with no reported recurrences to date. Two of these procedures were performed for recurrent hernias. We completed nine of nine attempted laparoscopic hernia repairs in liver transplant patients with epigastric incisional hernias. We repaired two of three attempted lower midline incisional hernias in renal disease patients. One of these patients was soon able to reuse his peritoneal dialysis catheter. A total of 15 patients, 12 with liver transplants, underwent open repair of their incisional hernias. These patients had seven recurrences and/or serious mesh infections with five patients electing repeated operations. In our initial series, laparoscopic mesh repair of incisional hernias is practical and safe in the abdominal organ transplant population with a low incidence of early recurrence and serious infections.     

Experience of Laparoscopic Incisional Hernia Repair in Kidney and/or Pancreas Transplant Recipients

Despite the wide popularity of laparoscopic incisional hernia repair (LIHR) in the nontransplant population, there are very few reports of LIHR available in abdominal organ transplant patients and none exclusively on kidney and/or pancreas (KP) transplant patients. We retrospectively reviewed a consecutive series of LIHR in KP transplant recipients performed over a period of 4 years and compared the results with LIHR in non‐transplant patients during the same period. A total of 36 transplant patients were compared with 62 nontransplant patients. There were five patients converted to the open procedure in the transplant and four in nontransplant patients (p‐NS). There were three seromas and one patient had a bowel perforation in the transplant group versus eight seromas, one bowel perforation and one small bowel obstruction noted in the nontransplant group. One patient in each group had a mesh infection requiring explant. Patients were followed up for a mean period of 2.2 years in the transplant group and 3 years in the nontransplant group. Overall there were five recurrences in the transplant group and four in the nontransplant group (p = NS). These results suggest that that LIHR is a safe and effective alternative to open repair.     

Open versus Laparoscopic Hiatal Hernia Repair

Background:

The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database.

Method:

The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality.

Results:

In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group.

Conclusion:

Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.