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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
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modied Sugarbaker technique in 2016, which combined a posterior components
release (transversus abdominis release or TAR) with the Sugarbaker repair [5]. We
often use this approach as it optimizes lateralization of the bowel conduit and
enhances mesh coverage area without the need for penetrating xation.
25.2 Indications forRepair
The most common indications for surgery are quality of life issues related to the stoma
appliance or discomfort related to bulging of the herniated contents and/or a history of
bowel obstruction [1, 2]. Due to the high recurrence rate and other postoperative com-
plications, asymptomatic patients can usually be managed non-operatively.
25.3 Preoperative Considerations
An extensive evaluation including a history and physical examination, basic laboratory testing and appropriate imaging, is recommended prior to surgical intervention.
A current computed tomography study of the abdomen and pelvis is recommended
for accurate diagnosis, assessment of anatomy and effective preoperative planning.
An up-to-date screening colonoscopy for patients over the age of 50years is also recommended. All major comorbid conditions must be addressed by means of a multidisciplinary approach before proceeding to the operating room. Patients with a current
smoking history must discontinue smoking for at least 4weeks before their surgery. It
is also important for diabetic patients to have their glycated hemoglobin level below
7.0% and the morbidly obese to achieve a body mass index of <40kg/m
2
.
25.4 Operating Room Set Up
A list of necessary equipment to perform a robotic-assisted Pauli modied
Sugarbaker parastomal hernia repair is shown in Table25.1. This includes a standard laparoscopy set of instrumentation.
Table 25.1 Equipment list
Laparoscopic
equipment
Robotic equipment • 10-mm 30-degree and 0-degree scopes (Si) or 8mm (Xi)
• 5-mm 30-degree scope
• Laparoscopic needle driver
• 5-mm Kii Fios First Entry
Margarita, CA) port
• Two 8-mm robotic ports
• 12-mm bariatric port for robotic camera (Si) or 8mm (Xi)
• Monopolar scissors
• ProGrasp™ grasper (Intuitive Surgical, Sunnyvale, CA)
• Mega Suture Cut™ needle driver (Intuitive Surgical)
• Monopolar cord
• Bipolar cord (optional if bipolar fenestrated grasper is used)
®
(Applied Medical, Rancho Santa
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
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25.5 Description ofTechnique
25.5.1 Initial Access andRetromuscular Dissection
An extended-view totally extraperitoneal (eTEP) approach is preferred in our practice. However, an intraabdominal approach may be considered if the patient has large
midline defects necessitating bilateral TAR.The initial steps of this procedure follow
an eTEP Rives-Stoppa repair in regard to accessing the retrorectus space (Chap. 20)
[6]. The patient is placed in a supine position with both arms tucked to the side and
then placed in steep Trendelenburg position with the lower extremities exed at a 30°
downward angle. The contralateral retrorectus space to the stoma is entered directly
using a 5-mm optical trocar. The retrorectus space is developed lateral to the linea
alba and medially to the neurovascular bundles (Fig.25.1a). A 12-mm camera and a
8-mm robotic working port are placed medial to the linea semilunaris (Fig.25.1b).
a
b
Fig. 25.1 (a) Accessing retrorectus space (b) Port placement relative to hernia defect. Example of
port placement. Blue: robotic working ports, Green: camera port, Diamond: Ostomy site
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A. Addo et al.
A crossover maneuver is performed to connect the bilateral retrorectus and preperitoneal spaces (Fig.25.2). This maneuver is initiated by incising the medial aspect of
the posterior rectus sheath in a longitudinal fashion. Once the preperitoneal space is
entered, the adipose tissue from the falciform and umbilical ligaments are swept
down, exposing the linea alba and the contralateral posterior rectus sheath. A longitudinal incision is made along the contralateral posterior rectus sheath and the retrorectus space to the hernia defect is entered and developed. It is crucial to avoid injury
of the linea alba during incision of the posterior rectus sheaths. Once the hernia sac
is encountered, it is sharply incised circumferentially creating a defect in the posterior layer (Fig.25.3).
Fig. 25.2 Performing crossover maneuver
Fig. 25.3 Dissecting around hernia sac
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
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25.5.2 Transversus Abdominis Release (TAR)
After development of the retrorectus space, we typically initiate the TAR by rst
developing the Space of Bogros (Fig.25.4). The posterior lamella and contributions
from the transversus abdominis muscle are then identied and divided medial to the
linea semilunaris (Fig.25.5), leaving the underlying transversalis fascia intact. The
retromuscular space, which now encompasses the retrorectus and pretransversalis
spaces, is developed by blunt dissection, which creates a large area for mesh placement and lateralization of the colonic conduit. It is our practice to develop the retromuscular space until the posterior layer lays at.
Fig. 25.4 Developing the
Space of Bogros
Fig. 25.5 Dividing the posterior lamella of the internal oblique
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A. Addo et al.
25.5.3 Lateralization ofConduit andClosure ofPosterior Layer
andParastomal Defects
Once the retromuscular space is fully developed, the posterior parastomal hernia
defect is extended laterally (Fig.25.6). This step is important as it aids in lateralization of the colonic conduit by shifting its entry point laterally as it enters the retromuscular space. Lateralization of the conduit is assisted by suturing it to the lateral
abdominal wall which is typically the aponeurotic portion of the transversus abdominis muscle (Fig. 25.7). The posterior layer defect is closed with 2–0 barbed
Fig. 25.6 Incising posterior layer and extending hernia defect laterally
Fig. 25.7 Lateralizing
bowel conduit
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
405
absorbable suture (Fig.25.8). The conduit should now enter the retromuscular space
laterally and exit medially through the rectus abdominis muscle. The goal is to have
between 5 and 7cm of the bowel conduit traversing the retromuscular space. The
anterior hernia defect is then closed in a running fashion with 0 barbed absorbable
suture (Fig.25.9).
Fig. 25.8 Closing posterior defect
Fig. 25.9 Closing anterior
defect
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A. Addo et al.
25.5.4 Mesh Placement
A macroporous medium-weight polypropylene mesh is trimmed to provide adequate
coverage of the entirety of the developed retromuscular space (Fig.25.10). A keyhole
is used to allow exit of the colon but we recommend that a minimum of 5cm circumferential overlap around the defect is achieved. In our practice, a closed-suction drain
is positioned over the mesh to prevent seroma formation in the early postoperative
period which could potentially compromise the integrity of the posterior layer.
25.6 Postoperative Management of Modified Sugarbaker with TAR
Patients are admitted to the oor and started on a clear liquid diet within 24h of
surgery. Postoperative pain is controlled with patient-controlled analgesia (PCA)
for the rst 24h. Patients are then transitioned to oral analgesia on the rst postoperative day. We prefer to await return of ostomy function prior to discharge which
results in a typical hospital stay between 2 and 3days. The retromuscular drain is
removed in clinic within a week.
25.7 Complications
Common complications include subcutaneous seroma formation associated with
dead space after reduction of large parastomal hernias. In a cohort of 12 patients
who recently underwent this procedure at our institution, one required drain
Fig. 25.10 Mesh placement
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
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placement by interventional radiology secondary to seroma formation. In addition, retromuscular dissection performed close to well-vascularized rectus muscles is associated with a higher risk of hematoma formation postoperatively.
There is also concern about the placement of mesh against the bowel conduit.
However, to date we have not seen any undesired effects associated with this,
including mesh erosion or bowel obstruction. One must consider the intimate
interaction of the mesh and bowel at the transition point from the intraabdominal
cavity into the retromuscular space. If the mesh has increased tightness near the
bowel conduit transition point the mesh should be incised to release tension.
Otherwise, mesh erosion of bowel may occur. Additionally, attention should be
taken intraoperatively to ensure that the mesh is snug but not strangulating the
conduit in that area.
25.8 Traditional Sugarbaker Repair
The above technique has recently evolved since the adoption of robotic technology
for hernia repair. There have been similar modications for various hernias that are
detailed elsewhere in this textbook. There has also been a prior history of the use of
the Sugarbaker with purely laparoscopic methods. This method has a longer history
than that described above. This more traditional method is presented below. It is
somewhat easier to adopt for the surgeon that is new to the robotically assisted
repair of ventral and parastomal hernias and especially those surgeons that are just
developing their skill sets with the posterior component separation method of any
hernia repair.
The robotic assisted laparoscopic repair does not differ from the laparoscopic
repair other than the use of the robot and the efciencies that it provides. The initial
goal is the dissection of all adhesions and identication of the anatomy of the hernia. This dissection can be hampered if there is difculty ascertaining the different
structures such as omentum and mesentery. This can be very difcult in the incarcerated hernias. Occasionally an internal hernia will also be identied, making this
separation of tissues especially challenging.
The initial workup should not differ from that noted earlier in the chapter. A
signicant loss of domain can make the minimally invasive option impossible. The
examination of the patient, the clinical status along with a preoperative CT scan will
greatly assist the approach to this problem. The latter evaluation is helpful in that it
can also identify the presence of additional hernias that are so frequent in the prior
midline incision. The surgeon can also assess the contents of the hernia, the size of
the defect, and the exact location of the defect(s). The laterally located herniation is
more challenging to repair than the more medially located one (resulting in a higher
recurrence rate).
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A. Addo et al.
25.8.1 Operating Room Set Up
In all cases the trocars will be inserted on the side of the abdomen opposite the location of the parastomal hernia (Fig.25.11). As noted in the gure, the location of the
camera will differ slightly for the two different robots. The location of the trocars
for the X robot will be identical to that of the Xi robot. Occasionally it will be helpful to add the fourth arm to the robot to repair these hernias when there is a signicant amount of adhesions or the habitus of the patient requires it but this is seldom
needed. The instruments that are preferred are not substantially different from that
of Table25.1 (Table25.2).
25.8.2 Initial Access andTechnique
The initial entry can be with the optical trocar noted above or one without the ability
to insufate via the obturator of the trocar itself. As shown in Fig.25.11, I will use
the 5mm port (not shown) to inspect the abdomen, but this will be replaced with a
12mm accessory port to allow introduction of suture and mesh and extraction of
needles during the operation. The use of the laparoscopic grasper may be needed to
dissect adhesions that prevent the safe insertion of the robotic trocars. The
ProGrasp™ is not often required with this method unless mesh must be removed as
part of the procedure. The need to heavily grasp tissues is not often required.
As with all intra-abdominal procedures for hernia repair, the initial phases of the
procedure will center on the lysis of adhesions (Fig.25.12). The reduction of incarcerated hernia contents will be the next order of business to allow for the delineation
of the fascial edges. For the use of the intraperitoneal onlay method that will be
described here, all adipose tissue that might be interposed between the mesh and the
Fig. 25.11 Port
placement—parastomal
(colostomy) hernia
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
Table 25.2 Equipment list
Laparoscopic equipment • 5-mm 0-degree scope
• Laparoscopic grasper
• Optical viewing trocar (5mm)
• 12mm trocar
• Suture passing device
Robotic equipment • 8mm (Xi) or 10-mm (Si) 30-degree camera
• Two 8-mm robotic ports
• 12-mm port for robotic camera (Si) or 8mm (Xi)
• Monopolar scissors (Intuitive Surgical, Sunnyvale, CA)
• Fenestrated Bipolar™ grasper (Intuitive Surgical)
• Mega Suture Cut™ needle driver (Intuitive Surgical)
• Mega™ Needle driver (Intuitive Surgical)
Fig. 25.12 Initial
dissection (prior midline
incisional and parastomal
keyhole hernia repair in all
gures)
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abdominal wall should be cleared away to allow for ingrowth of the tissues into the
selected mesh material.
After this has been accomplished, the defect and the area that will be covered by
the mesh will be measured by placing a ruler into the abdomen (Fig.25.13). The use
of the largest dimension is used to size the mesh. It is very important to obtain a
minimum of 5cm overlap (as noted above). in all directions using these measurements (Fig.25.14). Any additional overlap laterally will be benecial because this
area will most likely be the location of a recurrence. The fascial defect will then be
re-approximated with #2 permanent barbed sutures (Fig.25.15). Care must be taken
to avoid any compromise to the opening through which the intestine must pass to
avoid an obstruction.