Laparoscopic repair of ileal conduit parastomal hernia using the sling technique.

Laparoscopic parastomal hernia repair has become a viable option to overcome the challenges that face the hernia surgeon. Multiple techniques have been described over the last 5 years, one of which is the lateralizing "sling" technique, first described by Sugarbaker in 1980. In this study, we report the technique and our early results with the laparoscopic modified Sugarbaker repair of parastomal hernias after ileal conduit.     

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。     

��ǻ��Sugarbaker���������������Ч��������37�����棩

??Effect evaluation of laparoscopic Sugarbaker technique in the treatment of parastomal hernia??A report of 37 cases SHI Yu-long??LIU Jing-lei??GUO Xiao-bo??et al. Department of Gastrointestinal Surgery??Provincial Hospital Affiliated to Shandong University??Jinan 250021??China
Corresponding author??SHI Yu-long??E-mail??shiyl9889@126.com
Abstract Objective To investigate the results of laparoscopic Sugarbaker technique for patients with parastomal hernia. Methods The clinical data of 37 patients with parastomal hernia treated by laparoscopic Sugarbaker technique from February 2013 to December 2014 in Provincial Hospital Affiliated to Shandong University were analyzed retrospectively. Physiomesh or PCO mesh for parastomal hernia was used in all the patients. The intraoperative and postoperative data??complications and postoperative recurrence rate were analyzed retrospectively. Results Eight patients had postoperative complications. Postoperative intestinal obstruction ocuured in 4 patients; 2 of them were cured by non operative method and 2 patients were remissioned after colonoscopy expansion. Hernia sac effusion occured in 3 patients; 2 of them disappeared after ultrasound guided aspiration and 1 case complicated with infection was cured by drainage and rinsing. One patient with impeded bowel movement??abdominal pain before each defecation??recovered 1 month later. The mean follow-up was 13 months??during which two cases of recurrence were encountered. Part of the mesh moved from the edge into the the hernial sac in both of the two recurrent patients. One case of the recurrent hernia was repaired again and the other one was still under observation. Conclusion Laparoscopic parastomal hernia repair using the Sugarbaker technique is safe and feasible in experienced surgeons. Moreover??the method has the advantages of simple operation and low recurrence rate.     

Parastomal hernia: short-term outcome after laparoscopic and conventional repairs

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 +/- 58 vs 162 +/- 114 minutes, P = .06). The mean length of stay was 6 days for both groups (P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P < or = .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.     

Management of parastomal hernias

Stoma formation is a common aspect of general, colorectal, urologic, and oncologic surgical practice. Unfortunately, hernia formation around an ostomy trephine occurs in up to 50% of ostomates. In an era of explosive progress in abdominal wall surgery, parastomal hernia repairs remain plagued with technical challenges, high recurrence rates, and peri-operative morbidity. There is little expert consensus on the ideal operation. Repair type (suture or mesh based), surgical approach (laparoscopic, robotic, hybrid, or open), mesh configuration (cruciate, keyhole, or Sugarbaker), mesh type (permanent synthetic, biologic, or bioabsorbable), mesh location (underlay, sublay, or onlay) vary based on local expertise and patient clinical factors. This article will summarize the current literature on the management of parastomal hernias and provide expert commentary on our preferred practices for parastomal hernia repair.     

腹腔镜Sugarbaker七步法修补术在复发性造口旁疝的应用

目的探讨腹腔镜Sugarbaker七步法修补术在复发性造口旁疝中的应用价值。 方法收集2017年1月至2021年5月在中山大学附属第六医院行复发性造口旁疝修补术患者的临床资料和手术录像。评价复发性造口旁疝行腹腔镜Sugarbaker七步法修补的可行性，观察术后复发情况，并结合手术录像复盘分析造口旁疝的复发类型、术中和术后并发症以及术后恢复情况等。 结果共纳入11例复发性乙状结肠造口旁疝病例，均为Sugarbaker术后复发。其中男3例（27.27%），女8例（72.73%），年龄69（66~76）岁，体质指数27.11（24.80~27.55）kg/m²，病程12（4~24）个月。缺损长轴65.99（57.99~88.71）mm，缺损短轴60.96（49.82~87.00）mm。11例患者均顺利完成腹腔镜Sugarbaker七步法修补术，其中腹腔粘连分离时间30（5.50~35.50）min，缺损关闭时间32（25~46）min，总手术时间201（175~251）min，术中出血量20（10~50）ml。通过手术录像复盘，根据补片是否移位，可将造口旁疝复发类型分为补片移位型（9例，81.82%）和非补片移位型（2例，18.18%）。在补片移位型中，根据补片下缘移位的程度分为部分移位型（6例，66.67%）和完全移位型（3例，33.33%）。术后恢复排气时间2（1~4）d，术后住院时间5（4~7）d，无手术部位感染病例。1例术后出现肺部感染，经对症治疗后好转。中位随访时间34.7（27.53~60.40）个月，无复发病例。 结论复发性造口旁疝再次行手术治疗，腹腔镜Sugarbaker七步法修补术是安全可行的。     

Laparoscopic repair for recurrent parastomal hernia of an end stoma using the sandwich technique while preserving an ileal conduit: A case report

IntroductionParastomal hernia is a common complication following stoma creation. The surgical approaches included local repair by suture, stoma relocation and mesh-based techniques; but none has been able to provide satisfactory results.Presentation of caseA 60-year-old asian female was referred complaining of abdominal pain and constipation caused by recurrent parastomal hernia of an end stoma. She had undergone total cystectomy with creation of an ileal conduit at the age of 53 years, and laparoscopic sigmoid colostomy at the age of 55 years. Parastomal hernia of an end stoma had developed postoperatively, and she had undergone recreation of colostomy at the same place with fasciorrhaphy at the age of 59 years, but parastomal hernia recurred 6 months later because of split fascia sutures. Laparoscopic repair for recurrent parastomal hernia was conducted using the sandwich technique while preserving an ileal conduit. The patient has been followed postoperatively for more than 3 years without any sign of recurrence.DiscussionAlthough further cases are required to get definitive conclusions, we suppose that the laparoscopic sandwich technique can be useful for parastomal hernia.ConclusionWe herein report a case of recurrent parastomal hernia treated laparoscopically while preserving an ileal conduit using the sandwich technique which combines the keyhole and Sugarbaker techniques. This is a quite rare case report of laparoscopic repair for recurrent parastomal hernia in a patient with an ileal conduit.     

腹腔镜Sugarbaker法治疗造口旁疝疗效评估（附37例报告）

目的 评价采用腹腔镜Sugarbaker法进行造口旁疝修补的疗效。方法 回顾性分析2013年2月至2014 年12月山东大学附属省立医院收治的37例行腹腔镜Sugarbaker法修补造口旁疝病人的临床资料。均使用Physiomesh或PCO造口旁疝专用网片。分析病人术中及术后恢复情况、手术并发症、术后复发率等。结果 共8例病人出现术后并发症,其中4例病人出现术后肠梗阻,2例非手术方法治愈,2例行结肠镜扩张后缓解;3例病人出现原疝囊积液,2例经超声引导穿刺抽吸后消失,1例积液并发感染,经引流、冲洗后治愈;1例有排便不畅感觉,每次排便前有腹痛,1个月后消失。随访5～26个月,中位随访时间为13个月,共发现2例病人复发,均为部分网片从边缘进入原疝囊形成复发,1例再次手术修补,1例仍在观察。结论 腹腔镜Sugarbaker法修补造口旁疝安全可行,具有操作简单、复发率低等特点。     

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.     

"对位对线"补片固定法在腹腔镜造口旁疝Sugarbaker修补术中的应用

目的腹腔镜下Sugarbaker修补手术是造口旁疝的主要手术方式，补片固定是手术的关键技术环节，本研究介绍一种新式补片固定方法，并探讨其在临床上的应用效果。 方法回顾性分析2017年6月至2019年6月在中山大学附属第六医院住院的66例造口旁疝患者临床资料，患者均行腹腔镜造口旁疝修补手术（Sugarbaker术式），根据补片固定方式的不同分为试验组（41例，采用"对位对线"补片固定法）和对照组（25例，采用传统疝钉双圈补片固定方法）。比较两组患者相关指标和治疗效果。 结果两组患者性别、年龄、体质指数、病程以及造口旁疝分型比较，差异均无统计学意义。试验组补片固定时间短于对照组[（32.6±9.0）min vs（38.7±11.0）min，P<0.05]，两组在疝钉固定数量、血清肿、补片感染、术后住院时间指标方面，差异无统计学意义。试验组和对照组的平均随访时间差异无统计学意义[（37.6±14.8）个月vs（38.8±15.2）个月，P=0.687]，试验组的造口旁疝复发率低于对照组（2.4% vs 20.0%，P<0.05），而两组术后慢性疼痛发生率差异无统计学意义（24.2% vs 24.0%，P=0.971）。 结论在腹腔镜造口旁疝Sugarbaker修补术中应用"对位对线"补片固定法，可以缩短补片固定时间并减少术后复发，值得临床上推广使用。     

How I do it: novel parastomal herniorrhaphy utilizing transversus abdominis release

Introduction

Parastomal hernias are a complex surgical problem affecting a large number of patients. Recurrences continue to occur despite various methods of repair. We present a novel method of open parastomal hernia repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration.

Methods

A full mildline laparotomy is performed and all adhesions are taken down. We then perform an open parastomal hernia repair by utilizing retromuscular dissection, posterior component separation via transversus abdominis release, and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. We demonstrate this technique in a cadaveric model for illustrative purposes.

Discussion

This repair provides the benefits of an open posterior component separation with transversus abdominis release and maintains the biomechanics of a functional abdominal wall, all while simultaneously benefitting from the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our clinical experience with this novel technique to this point has been positive.

     

腹腔镜手术治疗造口旁疝的共识与争议

造口旁疝治疗较为复杂,总体疗效不如腹壁切口疝。腹腔镜手术治疗造口旁疝有较多的获益,但目前难以形成适用于所有病人和所有医师的临床解决方案。早期Keyhole手术开展较多,近年来Sugarbaker手术开展比例增高。现有“弱证据”指向的初步共识是Sugarbaker优于Keyhole,但在修补材料有待改进的情况下,Sugarbaker替代Keyhole尚为时过早,二者均有各自的临床适应证。腹腔镜修补结合造口原位重建技术在恢复造口功能等方面取得了非常好的效果。对于无明显重建指征的造口旁疝,也可在全腹腔镜下游离肠管、关闭缺损、缩小疝囊,既可将感染、造口相关并发症等风险降至最低,又可获得满意的疗效。近年来,各类腔镜腹膜外修补技术（EER）逐渐兴起,在造口旁疝领域,EER目前处于探索阶段,适应证有限。由于高质量、多中心、大样本RCT的匮乏,临床决策推荐尚缺乏高级别的证据支持,腹腔镜造口旁疝修补手术的术式选择争议还将持续。随着更多高质量文献的发表,相信外科医师一定能够在共识中解决争议,在争议后达成共识,为造口旁疝病人提供最佳的微创治疗策略。     

造口旁疝的发生机制和预防注意事项

国际上对造口旁疝的发生机制无明确解释,笔者尝试从理论角度分析造口旁疝的产生过程和形成机制,并阐述Sugarbaker和Keyhole术式应用补片预防造口旁疝的注意事项。     

补片修补造口旁疝38例疗效

目的总结造口旁疝应用Keyhole补片及超普平片进行疝修补术的疗效。 方法回顾性分析2005年1月至2018年4月,上海交通大学附属第六人民医院采用Keyhole补片及超普平片对38例造口旁疝患者行疝修补术治疗的临床资料。 结果38例造口旁疝患者均采用置入补片的疝修补术实施修补。其中15例行开放手术,6例行纯腔镜下腹膜内补片植入手术,5例行开放结合腔镜的杂交手术,12例行Lap-re-Do手术。手术时间40～300 min,平均（150±72）min。全部随访时间2～46个月,其中造口旁疝复发2例（缝合疝环、补片加固）,浆液肿4例,切口感染3例,造口肠管血运轻度障碍1例,均处理痊愈。 结论造口旁疝应积极应用补片行疝修补手术,疗效可靠。术式需根据术前仔细评估和术中情况做相应选择。     

Single center experience with the modified retromuscular Sugarbaker technique for parastomal hernia repair

Purpose

Parastomal hernias are challenging to manage, and an optimal repair has yet to be defined. An open, modified, retromuscular Sugarbaker technique has recently been described in the literature as a technically feasible approach to parastomal hernia repair. This study evaluates our initial institutional experience with parastomal hernia repair with the aforementioned technique with respect to safety and durability.

Methods

All patients who underwent an open, modified retromuscular Sugarbaker parastomal hernia repair from 2014 through 2016 at our institution were identified. Patient characteristics, hernia variables, operative details, and 30-day and medium-term outcomes were abstracted from the Americas Hernia Society Quality Collaborative database. Outcomes of interest included 30-day wound morbidity, mesh-related complications, and hernia recurrence.

Results

Thirty-eight patients met inclusion criteria. 20 (53%) patients presented to our institution for management of a recurrent parastomal hernia. 35 (92%) patients had a concurrent midline incisional hernia with a mean total hernia width of 15.1 cm and mean defect size of 353 cm². Thirty-day wound morbidity rate was 13%. At a mean of follow-up of 13 months (range 4–30), the hernia recurrence rate was 11%. Three patients (8%) experienced mesh erosion into the stoma bowel, leading to stoma necrosis, bowel obstruction, and/or perforation which required reoperation at day 8, 12, and 120 days, respectively.

Conclusions

The outcomes of the retromuscular Sugarbaker technique for the management of parastomal hernias have been disappointing at our institution, with a concerning rate of serious mesh-related complications. This operation, as originally described, needs further study before widespread adoption with a particular focus on the technique of mesh placement, the most appropriate mesh selection, and the long-term rate of mesh erosion.

     

Revisional Laparoscopic Parastomal Hernia Repair

Background:

We herein report a laparoscopically performed re-do operation on a patient who had previously undergone a laparoscopic parastomal hernia repair.

Case Report:

We describe the case of a 71-year-old patient who presented within 3 months of her primary laparoscopic parastomal hernia repair with recurrence. On relaparoscopy, dense adhesions to the mesh were found, and the mesh had migrated into the hernia sac. This had allowed loops of small bowel to herniate into the sac. The initial part of the procedure involved the lysis of adhesions. A piece of Gore-Tex DualMesh with a central keyhole and a radial slit was cut so that it could provide at least 3 cm to 5 cm of overlap of the fascial defect. The tails of the mesh were wrapped around the bowel, and the mesh was secured to the margins of the hernia with circumferential metal tacking and 4 transfascial sutures. The patient remains in satisfactory condition and no recurrence or any surgery-related problem has been observed during 8 months of follow-up.

Conclusion:

Revisional laparoscopic repair of parastomal hernias seems feasible and has been shown to be safe and effective in this case. The success of this approach depends on longer follow-up reports and standardization of the technical elements.     

The modified laparoscopic keyhole parastomal hernia repair with in situ re-ostomy has low recurrence rate

Purpose

This study aimed to present a modified laparoscopic keyhole parastomal hernia repair technique with in situ re-ostomy and show its safety and feasibility at a mid-term follow-up.

Methods

The technique begins with adhesiolysis during laparoscopy. An annular incision is made between the skin and stomal mucosa. Then, after all adhesions of the stomal bowel and its mesentery are separated from the hernial sac, the stomal bowel is delivered through the keyhole mesh. The mesh is then stitched to the stomal bowel and placed intraperitoneally. The hernial ring is narrowed, and the mesh is further stitched to the hernial ring and stomal tube. After the mesh is fixed, the redundant stomal bowel is shortened, and a new in situ stoma is matured in the conventional way.

Results

Altogether, 65 consecutive patients underwent successful hernia repair via a modified laparoscopic keyhole with in situ re-ostomy. Two of the patients had recurrent parastomal hernias. No mortalities occurred during the perioperative period. Morbidities included two cases of seroma and three of ileus, all of which were cured with conservative treatment. In addition, one case of intestinal perforation was rescued by intestinal resection and enteroenterostomy. Median follow-up was 29 months (range 3–60 months). No complications of mesh-related infection or patch erosion were noted during the follow-up.

Conclusions

Modified laparoscopic keyhole parastomal hernia repair with in situ re-ostomy is a safe procedure with a low recurrence rate at the mid-term follow-up.

     

Laparoscopic parastomal hernia repair using a nonslit mesh technique

Background The management of parastomal hernia is associated with high morbidity and recurrence rates (20–70%). This study investigated a novel laparoscopic approach and evaluated its outcomes. Methods A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence. Results A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m² underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm², and the mean size of the mesh was 365 cm². There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2–38 months), 4% (1/25) of the patients experienced recurrence. Conclusion On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands. Presented at the Plenary Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2006 Annual Meeting, Dallas, Texas, April 2006     

Parastomale Hernienversorgung mit prothetischer Netzplastik

After stoma formation, parastomal hernia develops in 30–50% of patients, with one-third of these require operative correction. Recurrence rates are very high after suture repair of parastomal hernias or relocation of the stoma. Open or laparoscopic mesh repairs have resulted in much lower recurrence rates. Long-term follow-up of the various techniques for parastomal hernia repair is lacking, as are randomized trials. A prophylactic prosthetic mesh placed in a sublay position at the index operation has reduced the rate of parastomal hernia in randomized trials. A prophylactic mesh in an onlay position, a sublay position, and an intraperitoneal onlay position has also been associated with low herniation rates in non-randomized studies. Although several questions within this field still have to be answered, it seems obvious that use of a mesh represents a suitable measure for the prevention of parastomal hernia as well as parastomal hernia repair.     

��ǻ���޲����������ʽѡ��ͼ���Ҫ��

??Key points and choice of laparoscopic parastomal hernia repairs HE Kai??YAO Qi-yuan. Department of General Surgery??Huashan Hospital??Fudan University??Shanghai 200040??China
Corresponding author??YAO Qi-yuan??E-mail??wyhernia@yahoo.cn
Abstract Totally laparoscopic para-colostomal hernia repairs have high postoperative recurrent rate. Laparoscopic Sugarbaker repair has a good effect for ileo-parastomal hernia. Lap-re-Do shows better outcome than totally laparoscopic hernia repairs on para-colostomal hernia. Laparoscopic Sugarbaker repair is recommended for the early para-colostomal hernia and para-ileostomal hernia with small hernial sac. Lap-re-Do may be better for the most para-colostomal hernia.