Reading Time:

9 minutes
Laparoscopic Parastomal and Incisional Hernias

Laparoscopic Parastomal and Incisional Hernias

“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

“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

Laparoscopic hernia repair is a new, less-invasive, and safer procedure that may be used for incisional and parastomal hernias. The procedure is another alternative for ostomy patients with colostomies, ileostomies or urostomies. It 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)

“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

“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

“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, the hernial sac is pushed inside the abdominal cavity. The defect stays open but it is covered with a permanent mesh graft placed under the abdominal muscles. Laparoscopic incisional hernia repairs have fast recovery (two-three days) because there is no incision of the abdominal wall. In the open procedure, there is re-incision that bears considerable trauma and requires nursing of a large wound. Esthetically, the laparoscopic procedure goes almost unnoticed.

“We routinely use a 30° camera. Scissors and two graspers have to be prepared for laparoscopic hernia repair. The screen is placed at the opposite of the surgeon. The patient is placed in a supine position with both arms unabducted under general anesthesia. A single shot of antibiotics is given preoperatively. The site of trocar placing depends on the localization of the hernia. If the hernia is localized in the right hemiabdomen, the trocars should be placed on the left side. Using a limited open technique, the pneumoperitoneum is established and the optical trocar is inserted, and under direct vision, a minimum of two additional trocars at a suitable distance from the hernial orifice are inserted. Alternatively, the pneumoperitoneum can be established using a Verres-Needle. After establishing the pneumoperitoneum at 12 mmHg a diagnostic laparoscopy is performed. Adhesions between the omentum or intestine with the anterior wall surrounding the hernial orifice are divided, and the content of the hernia is reduced completely. Adhesiolysis has to be Updated Topics in Minimally Invasive Abdominal Surgery performed with scissors and performed with scissors and without electrocoagulation under direct vision to avoid bowel lesions. In cases of incarceration the necrotic tissue has to be resected. If there is not enough working space or the trocars are not correctly placed an additional trocar can be helpful.”7

“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
  • Idividual 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

“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

There are two types of laparoscopic parastomal techniques: “keyhole” and “sugarbaker”. In keyhole repairs, the parastomal hernia is fixed 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.

“Modified Sugarbaker technique was first described by Stelzner et al. in 2004. By laparotomy, an intraperitoneal expanded polytetrafluoroethylene mesh was placed with overlap the edges of the fascia by at least 5 cm in all directions. In 20 patients, with a mean follow up of 3.5 years, they saw three asymptomatic recurrences.”11

“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.”12

After repair, the instruments are taken away and the incisions sutured. 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.

As with the open procedure, incisional hernias and parastomal hernias have a propensity to reoccur. It is advisable to wear ostomy support or an ostomy 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

 

References

(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, 12, 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

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

Leave a Reply

If you would also like a response sent to your email please add it in the email box below.