Laparoscopic hernia repair is a new, less-invasive, and safer procedure to treat incisional and parastomal hernias. It is an alternative for ostomy patients with colostomies, ileostomies or urostomies. The procedure consists of three punctured openings on the abdomen, one for the scope (to view) and the other two for the instruments (to operate on the hernia).
“The concept of minimally invasive surgery has been present for millennia, and started with the advent of endoscopy of the rectum, vagina, ear, and nose. Hippocrates first described a rectoscope in the 4th century. Later in the 10th century, Albukasim, an Arab physician, developed methods of speculum illumination with candlelight and mirrors. In the early 19th century, Phillipp Bozzini utilized the centrally bored mirror for his cystoscope. In 1879, Maximilian Nitze improved the cystoscope, adding a platinum wire electric light source and developing the first endoscopic photographs.”1
Historical Background of Laparoscopic Procedures
“In 1901, the German surgeon George Kelling insufflated a dog’s abdomen and viewed the viscera with the Nitze style cystoscope. A Swedish surgeon, Hans Christian Jacobaeus, performed the same procedure that year and coined the term laparoscopy. The new procedure of diagnostic laparoscopy then spread around the world. Innovations were rapidly added, such as needle induced pneumoperitoneum, 45-degree laparoscopes, trocar insertion, and insufflation machines. In 1933, Heinz Kalk, a German gastroenterologist, pioneered many of these techniques. He developed a dual trocar technique and a wide-angle scope to obtain biopsies. Visualization improved remarkably in the 1950’s with the Hopkins lens and fiberoptic cold illumination; however, interest in these techniques waned for several decades. Gynecologists began experimenting again in the 1970’s with tubal ligation, oocyte harvesting, and tumor biopsies. In 1971, Harrith Hasson developed a technique to safely enter the abdomen with his new trocar. Kurt Semm performed the first laparoscopic appendectomy in 1983, and went on to perform a total of 20000 procedures. The German surgeon Erich Muhe performed the first laparoscopic cholecystectomy in 1985, but was not initially received well by his peers. This was followed by an explosion of laparoscopic procedures, including the first laparoscopic ventral hernia repair done by LeBlanc and Booth in 1993.”2
Incidence of Parastomal Hernias
“Parastomal hernias have been shown to occur in up to 48% of patients with a colostomy or 36% for patients with an ileostomy, with the rate rising the longer the follow-up. This is not surprising given the fact that the stoma is essentially a hernia. The best treatment for a parastomal hernia is, of course, a reversal of the ostomy. However, for patients with a terminal ostomy, this reversal is not an option, and surgical options up to now have proven disappointing. For this reason, the indications for repair have been narrow. Indications for the repair include incarceration causing pain, obstruction, bleeding, and stoma appliance malfunction. The latter can be extremely distressing to some patients, have negative psychological effects, and destroy the patient’s relationships. Until now, surgical options have been limited, in addition to having significant morbidity and high recurrence rates. Because most parastomal hernias are still being repaired via a laparotomy incision, this type of repair alone implies a lifetime risk of an incisional hernia formation of up to 30%. Basically, treatment options include resisting the ostomy, which has a recurrence rate of up to 76%; however, there is an added risk of an incisional hernia at the ostomy site and onlay mesh repair with recurrence rates up to 70%. Open techniques involving placement of the mesh intraperitoneally with a hole for the stoma suffer from an intrinsic fault that the hole will allow herniation sooner or later, especially given that all meshes will shrink to some extent with time, further enlarging the hole and thus encouraging herniation.”3
Incidence of Incisional Hernias
“Laparoscopic repair for abdominal incisional hernia with anti-adhesion mesh has been widely adopted nowadays. Data from USA in 2013 revealed that about 20–27% of repairs for ventral and abdominal incisional hernias were performed laparoscopically. In meta-analysis, there is no difference in recurrence between laparoscopic and open repair for ventral and incisional hernias, but the laparoscopic repair has the merit of reducing surgical site infective complication when compared with open repair (1.6% vs. 10.1%). The major operative steps of laparoscopic repair of ventral incisional hernia include ports positioning, adequate adhesiolysis, defect closure and mesh fixation. On the other side, in view of the clinical heterogeneity in location, quantity and size of abdominal incisional hernia, the repair strategy can be very challenging in some cases. In this article, we present a case with multiple hernias (swiss-cheese lesions) in one long midline incision repaired with double anti-adhesion mesh by IPOM technique.”4
“In an attempt to further reduce parietal trauma, single-incision laparoscopic surgery (SILS) has become increasingly popular in many surgical disciplines, including herniology, although conclusive evidence of its superiority over conventional multiport surgery still awaits prospective randomized controlled studies.”5
Laparoscopic Incisional Hernia Repair
“A certain percentage of patients is not aware of their hernia (asymptomatic). In our experience, incisional hernia is often only diagnosed during cancer follow-up examinations. In personal communications, this observation has been confirmed by various European surgeons. Patients with incisional hernia usually report rather nonspecific symptoms and occasionally experience pain and gastrointestinal problems, such as a postprandial feeling of fullness. Larger hernias may be associated with lesions of the skin overlying the hernia sac or with chronic spinal complaints. If the hernia sac is large, a portion of the small intestine may protrude through the abdominal wall, significantly complicating surgical repair. It is not uncommon that patients with incisional hernia experience social exclusion and are limited in their ability to work. In addition, self-care may be substantially impaired”6
During a laparoscopic incisional hernia repair, a surgeon pushes the hernial sac inside the abdominal cavity. The defect stays open but it is covered with a permanent mesh graft under the abdominal muscles.
Laparoscopic incisional hernia repairs have fast recovery (two-three days) as there is no incision of the abdominal wall. In the open procedure, the re-incision bears considerable trauma and requires nursing of a large wound. Esthetically, the laparoscopic procedure goes almost unnoticed.
A laparoscopic intervention with esthetic results may cause additional expenses. “On the one hand, operative costs of laparoscopic incisional hernia repair compared to open surgery are significantly higher due to expensive surgical tools in laparoscopy. On the other hand, in hospital costs are significantly lower in laparoscopic surgery due to shorter hospital stay, lower infection rate and less postoperative pain. However, laparoscopic incisional hernia repair is associated with significant lower overall costs. Therefore laparoscopic incisional hernia repair is cost effective”7
Pros and Cons
“The great challenge of incisional hernia surgery remains to reconcile the variability of the condition (e.g. risk factors and hernia characteristics) with the surgical options available (e.g. surgical techniques, surgical materials, and expertise). As in all fields of medicine, the variability of the condition makes tailoring treatment to the patient and generating evidence difficult. However, this balancing act has been performed more successfully in recent years, as shown in the highly recommended review by Berger which complements the topic. Reintegration of patients into the labor market is influenced by the following parameters:
- Clinical picture / signs and symptoms
- Impairment of quality of life
- Individual risk factors
- Morphology of the hernial orifice
- Size of the hernia sac and hernial orifice
- Restoration of abdominal wall function.”8
“Advances in surgical techniques have opened a whole new range of possibilities: Both the use of hybrid/conventional-endoscopic procedures (e.g. EMILOS) and surgical robots have enabled us for the first time to place the mesh in a retromuscular position (e.g. r-TAR). Last but not least, prevention of incisional hernia, e. g. by refining the technique of abdominal wall closure or prophylactic mesh placement in high-risk patients, will be of particular importance in the future.”9
Laparoscopic Parastomal Hernia Repair
“Parastomal hernia is the most common complication in various types of stomas. It can progress almost asymptomatically, often resulting only in an abdominal deformity in the vicinity of the stoma, but in extreme cases it can lead to bowel incarceration and strangulation, thus necessitating immediate surgery. It is estimated that at present, approximately 1 in 3 patients suffering from this complication are treated surgically, which is partly explained by the high recurrence rate observed after repair. This led to the emergence of the concept of primary prevention using prosthetic mesh, particularly since many experts claim that the incidence of parastomal hernia is practically unavoidable and to a considerable extent simply a matter of time”10
Types of Laparoscopic Parastomal Hernia Repair
There are two types of laparoscopic parastomal techniques: “sugarbaker” and “keyhole”.
In keyhole repairs, surgeons fix the parastomal hernia with an intraperitoneal (inside the abdominal wall) mesh having an opening to allow the intestine through. In “sugarbaker” or “modified sugarbaker” repairs, the mesh is placed intraperitoneally as well but without the opening. The mesh covers the entire defect and surroundings of the intestine.
After repair, surgeons withdraw the instruments and suture the incisions. In a follow-up appointment, the surgeon removes the sutures and may place butterfly stitches, which are thin adhesive strips that hold the edges of the wound together as a Band-Aid.
“Laparoscopic repair of a parastomal hernia with a modified Sugarbaker technique can be a safe and technically feasible. It is a mechanically logical technique combining the advantages of minimally invasive surgery with a favorable intra-abdominal pressure gradient. The viability of this approach, however, depends on longer-term follow-up reports with greater statistical power, and standardization of technical details.”11
“The second method of parastomal hernioplasty is referred to as a “keyhole” technique. In this technique, a 2 to 3 cm “keyhole” cut-out is made to surround the ostomy while covering the entire hernia defect (g. 4). How-ever, there is a risk of obstructing the enterostomy if a small keyhole is made and a risk of recurrence if the keyhole is large. Fenestrated mesh is then mounted to the fascia by means of single interrupted sutures or se-cured with titanium tacks ensuring the overlapping is performed, as in Sugarbaker’s procedure.”12
Natural Progression of Hernias
As with the open procedure, incisional hernias and parastomal hernias may reoccur. Wear an ostomy support or hernia belt on a daily basis for prevention purposes.
“The natural progression of hernias—including parastomal hernias—is one of progressive enlargement with time. Parastomal hernias can cause typical problems, including incarceration, obstruction, and a cosmetically unpleasant bulge. However, as the parastomal hernias enlarge during the day during periods of mobility, the ostomy appliance when applied during this period tends to become dislodged at nighttime when some or all of the parastomal hernia contents reduce. This circumstance causes highly unpleasant fecal/urinary soiling in bed, which can lead to psychological distress and relationship problems. This aspect of parastomal hernia complications is often underappreciated. Until now, the treatment options and results have been extremely limited and poor. Consequently, although ventral/incisional hernias are being repaired routinely to prevent complications, the laparoscopic repair has revolutionized repair practices by significantly reducing complications and improving success rates to >95%. The poor results of conventional surgical options, including resisting and open underlay or onlay mesh repair with a slit technique, mean that most surgeons would contemplate parastomal hernia repair only for significant symptoms as mentioned above.”13
Laparoscopic hernia repairs are associated with lower risk of infection, shorter operation time, smaller incision size and earlier return to daily activities and work. Consult with your surgeon if you have any questions regarding your operation, as well as preoperative and postoperative recommendations.
(1, 2) Laparoscopic repair of parastomal and incisional hernias with a modified Sugarbaker technique. Vorst, A., Kaoutzanis, C., Carbonell, A., & Franz, M. World Journal of Gastrointestinal Surgery. 2015. https://www.wjgnet.com/1948-9366/full/v7/i11/293.htm
(3, 5, 13) Single-Port Laparoscopic Parastomal Hernia Repair with Modified Sugarbaker Technique. Tran, H., Turingan, I., Zajkowska, M., & Tran, K. Journal of the Society of Laparoendoscopic Surgeons. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939339/
(4) Laparoscopic repair of multiple incisional hernias in a single midline incision by double composite mesh. Yang, X., Jiang, L., Li, Y., Liu, J., & King-Man Fan, J. Journal of Visualized Surgery. 2018. http://jovs.amegroups.com/article/view/18850/18913
(6, 8, 9) The Treatment of Incisional Hernia. Dietz, U., Menzel, S., Lock, J., & Wiegering, A. Deutsches Ärzteblatt International. 2018. https://www.aerzteblatt.de/int/archive/article?id=195731
(7) Laparoscopic Incisional Hernia Repair. Kurmann, A., & Beldi, G.Updated Topics in Minimally Invasive Abdominal Surgery. 2011. https://www.intechopen.com/books/updated-topics-in-minimally-invasive-abdominal-surgery/laparoscopic-incisional-hernia-repair
(10) Parastomal hernia – current knowledge and treatment. Styliński, R., Alzubedi, A., & Rudzki, S. Videosurgery and Other Miniinvasive Techniques. 2018. https://www.termedia.pl/Parastomal-hernia-current-knowledge-and-treatment,42,31466,0,1.html
(11) Laparoscopic repair of parastomal and incisional hernias with a modified Sugarbaker technique. Jeong, D., Park, M., Melich, G., Hur, H., Min, B., Baik, S., & Kim, N. Journal of the Korean Surgical Society. 2013. https://synapse.koreamed.org/DOIx.php?id=10.4174/jkss.2013.84.6.371
(12) Parastomal Hernia – Contemporary Methods Of Treatment. Skibiński, R., Pasternak, A., Szura, M., Solecki, R., Matyja, M. & Matyja, A. (2015). Polish Journal of Surgery. 87. 10.1515/pjs-2015-0100. https://www.researchgate.net/publication/291390243_Parastomal_Hernia_-_Contemporary_Methods_Of_Treatment