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370 L.A. Israelsson
Fig. 23.6 Technique of subcutaneous parastomal hernia repair. ( a ) The
old midline incision is opened, and well above the stoma the incision
can be extended laterally. ( b ) The stoma is approached in the subcuta-
is tolerant of sepsis and simple local infection will usually
settle with the prosthesis remaining in place.
The sublay technique places the mesh around the stoma in
the plane between the posterior rectus sheath or peritoneum
and the parietal muscles.
An IPOM can be placed with either an open or a laparoscopic technique. Then the surface facing abdominal contents should be of a nonreactive material so that adhesions
are not formed. The ePTFE mesh has previously been commonly used although it is very prone to infection in contaminated areas and if an infection occurs the mesh must be
removed. There are today several meshes available that allegedly provide a nonadhesive surface towards the intestines.
The laparoscopic approach offers the surgeon the ability
to visualize the entire abdominal wall so that any incisional
hernias may also be repaired at the same time. This technique requires that the prosthetic biomaterial be placed in the
intraperitoneal position. The laparoscopic approach is
described into detail in Chap.
24 .
neous layer. ( c ) The sac is reduced and the mesh introduced. ( d ) The
mesh surrounds the stoma and is fi xed by quilting sutures to the underlying external aponeurosis
Technique of Subcutaneous Prosthetic Repair
An adherent wound drape is used to occlude the stoma and
restrict contamination. A midline incision is made and
extended 10 cm cranially to stoma and may also be extended
laterally to enable dissection around the hernia (Fig. 23.6 ).
The incision is deepened to the aponeurosis. The sac is
found, opened, and its contents reduced. The peritoneum is
closed. A sheet of polypropylene mesh is prepared with a
hole in it to allow the egress of the stoma and a cut is made
in the mesh so that it can be positioned. The mesh is introduced around the stoma and quilted down to the aponeurosis. The cut made in the mesh to enable it to be placed around
the stoma is sutured with a nonabsorbable mono fi lament
suture. The mesh should extend at least 5 cm outside the
margins of the aponeurotic defect and is fi xed by quilting
sutures to the external aponeurosis. If possible, a cuff of
mesh should surround the emergent stoma. Suction drains
may be inserted.
Technique of Extraperitoneal Prosthetic Repair
The patient is prepared with the stoma sealed with an adherent plastic fi lm. The original laparotomy scar is reopened.
A plane of dissection is opened between the posterior
sheath or peritoneum and the parietal muscles lateral to the
stoma. During this dissection, the hernial contents are
reduced, if possible without opening the hernia sac. This
may not be possible. If the peritoneum is opened, it is
closed carefully around the stoma so that the mesh can be
introduced into the extraperitoneal plane (Fig.
A sheet of polypropylene mesh is prepared, to repair
the defect, with a hole in it to allow the egress of the
stoma. A cut is made in the mesh so that it can be positioned. The polypropylene should fi t snugly around the
efferent bowel and should overlap the margins of the
defect by at least 5 cm. The polypropylene is quilted into
place. Suction drains may be positioned. If there is any
defect in the main wound, the margin of the mesh is
extended medially to overlap and repair this defect.
23.7 ).
The Sugarbaker Technique of Open IPOM Repair
Repair in this fashion has been described by Sugarbaker and
utilizes the old laparotomy incision for access to the abdominal cavity [ 62, 63 ] . Berger has developed a modi fi ed version
of this method in laparoscopic repair of parastomal hernias
[ 64, 65 ] . The ostomy is covered by a plastic adhesive drape
to seal this site and minimize the potential for contamination.
The abdomen is entered and the contents of the hernia are
dissected free from the edges of the aponeurotic defect. Care
must be taken to preserve the vascular supply to the bowel
during this dissection. It is not necessary to dissect or remove
the peritoneal sac of the hernia itself. An accurate measurement of the defect will allow the appropriate sizing of the
biomaterial. A minimum of a 5-cm overlap is probably mandatory (Fig. 23.8 ).
The prosthesis can be fi xed to the abdominal wall in a
variety of methods. It is usually helpful if the colon is sutured
to the lateral abdominal wall by either permanent or absorbable sutures. The mesh should be positioned to provide the
necessary amount of overlap so that the intestine is “lateralized” in relation to the exit of the stoma. The biomaterial will
be more easily fi xed at this point by the use of tacks. The use
of additional sutures provides the most assurance that the
biomaterial will achieve permanent fi xation. These can be
placed intraperitoneal to avoid the possibility of contamination of the operative fi eld by the contents of the ostomy.
37123 Parastomal Hernia
The results reported by the above open technique in the
limited number of seven patients were favorable [
There were no recurrences or complications after 4–7
years of follow-up. The importance of this technique
today is its impact on the development of recent laparoscopic techniques.
63 ] .
Technique of Stoma Relocation
The new stoma site must be precise and careful. One in
the lower abdomen overlying the contralateral rectus muscle and away from old incisions and skin creases is preferred. Commonly the location will be at the precise
contralateral abdominal location. Preoperative consultation with the enterostomal nurse is essential to the
identi fi cation of the ideal location and the site will be
marked at that time.
A problem, which should be foreseen, is distortion of
the abdominal wall by surgery after the operation has
begun. The laxity of the musculature caused by anesthetic
paralysis and the positioning of the patient on the operating table can result in a signi fi cant change in the habitus
of the patient. Additionally the operative manipulation
of the skin and muscle can result in lateral undermining of
the tissues, which can eventuate in a poorly constructed
stoma.
The ostomy is covered by a plastic adhesive drape to
seal this site and minimize the potential for contamination.
Approaching the operation via a midline laparotomy incision greatly facilitates the operation. The stoma is straightened out from the abdominal cavity; an everted ileostomy
is uneverted, and then closed. The easiest way of closing
the bowel is using one of the linear stapling devices available. This will avoid any contamination and generally
results in a closed ostomy that is easy to manipulate.
Theoretically, the exposed end of the staple row can be a
source of infectivity and one can cover the end of the staple line with gauze if desired. The short cut off bowel end
distal to the staple line is left until the operation is completed, wounds have been closed and draped, and is then
easily excised through the stoma opening. This part of the
bowel is most often expendable as scarring and distortion
makes it useless for a new ostomy. The circular skin defect
after the stoma can be narrowed with a subcuticular absorbable mono fi lament purse-string suture. Although this
leaves a skin defect with a diameter of up to 2 cm, late
cosmetic results are very good as activated dermatomyo fi brils
within days will contract and markedly lessen the size of
the defect. As the skin opening allows the wound to drain
wound infection will be rare.
372 L.A. Israelsson
Fig. 23.7 Technique of extraperitoneal prosthetic repair.
( a ) Reopening the laparotomy incision. ( b ) Developing the extraperi-
toneal plane to the stoma. ( c ) Preparing the mesh to make the repair.
To construct the new stoma, it is necessary to be sure of
the following:
1. A very adequate length of intestine—ileum for ileostomy,
colon for colostomy—must be mobilized so that the new
stoma can easily be constructed with no degree of tension.
2. There is no need to close “lateral spaces” around a stoma.
The stoma should be placed close to the middle of the
rectus sheath; the “spaces” on either side of it are then
vast and are left entirely open. Postoperative strangulation
of intestine in such a large defect is unlikely.
3. A prophylactic mesh is placed in a sublay position according to the principles for a prophylactic mesh previously
described. Without a prophylactic mesh recurrence rates
are uncomfortably high.
A defect in the abdominal wall with a diameter of more
than 2 cm usually cannot be closed by simply suturing it
without a high proportion of incisional hernias developing.
As the defect after a parastomal hernia is always larger than
2 cm, a mesh repair is warranted. This is the rational for
combining a prophylactic mesh at the new stoma site with a
large sublay mesh covering the midline incision—where a
concomitant incisional hernia may be present—and the original stoma site. Provided that the midline incision can be
closed and the abdominal wall defect at the primary site is
not too large, one large low-weight, large-pore mesh can be
used for covering all these locations. If the defects are so
( d ) Placing the polypropylene in place to the muscle layer and
super fi cial to the peritoneum—in the extraperitoneal plane again like
“ham in a sandwich”
large that the aponeurotic edges must be sutured to the mesh,
a stronger mesh should be used for the defects in the midline
and at the parastomal hernia site (Fig. 23.9 ).
The midline is closed with a running mono fi lament nonabsorbable or slowly absorbable suture. This suture must be
with a suture length to wound length ratio of more than 4. To
minimize the risk of wound infection and incisional hernia,
the high suture length to wound length ratio should be
achieved with many small tissue bites placed 5–8 mm from
the wound edge [ 66 ] . The skin is closed with a subcuticular
suture of a mono fi lament absorbable suture.
Postoperatively appropriate stoma care should be instituted. The general principles for fast-track abdominal surgery should be utilized with swift resumption of meals and
activity together with adequate nonmorphine-based analgesics [ 67 ] . If despite these measures being taken some degree
of postoperative adynamic ileus appears, it may be followed
by hyperactivity of the stoma, which may necessitate intravenous fl uid replacement after the operation.
Conclusions
Creating an ostomy is a common surgical procedure utilized in both elective and emergent situations. This development has been greatly facilitated by the improvement of
37323 Parastomal Hernia
Fig. 23.9 A parastomal hernia is relocated from the left lower quadrant to
the right quadrant. A low-weight large-pore mesh 10 by 10 cm is placed as
a prophylactic mesh at the new stoma site. A stronger mesh covers any
defect in the midline and the defect at the parastomal hernia site
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Fig. 23.8 The Sugarbaker technique of open IPOM repair. ( a ) Position
of the lateralized colon onto the sidewall of the abdomen prior to the
placement of the biomaterial. This must usually be sutured into place to
maintain this position. ( b ) Completed repair of the parastomal hernia.
Note that the biomaterial covers the hernia defect as well as the lateralized intestine
modern stoma bandages that now enable an easy and
reliable stoma care.
Parastomal hernia develops in 30–50% of patients
supplied with an ostomy and one-third of these demand
repairs.
In randomized trials a prophylactic prosthetic mesh placed
in a sublay position has reduced the rate of parastomal hernia. Also in nonrandomized studies a prophylactic onlay,
sublay, or IPOM has been associated with low herniation
rates.
After suture repair or relocation of the stoma recurrence
rates are unacceptably high. With open or laparoscopic mesh
repairs considerably lower recurrence rates are reported.
There are no randomized trials or long-term follow-up available presenting results with these various techniques for
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37523 Parastomal Hernia
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The Laparoscopic Repair of Parastomal Hernias
Dieter Berger
2 4
Introduction
The parastomal hernia is a very common complication after
the creation of any ostomy [
believed that most patients with parastomal hernias do not
suffer from symptoms, the contrary could be clearly shown
in a recent publication [ 2 ] . In fact, more than 80% of the
patients with a clinically detectable hernia have problems
that interfere with their daily activities because of the hernia.
Today the repair should include the use of non-resorbable
meshes. Nevertheless the results of clinical studies are discouraging because of recurrence rates between 10 and 50%
and a substantial frequency of wound complications [ 3 ] .
However most studies only contain a limited number of
patients and therefore do not allow de fi nite conclusions.
The laparoscopic approach is gaining increasing popularity not only for the repair of incisional but also for parastomal hernias. One main advantage of the laparoscopic over
the conventional approach is the reduced rate of wound complication which has been clearly demonstrated [ 4 ] .
Laparoscopically the mesh is placed intraperitoneally according to Sugarbaker [ 5 ] , in a keyhole fashion or using the so-
called sandwich technique.
1 ] . Although it is generally
Keyhole Technique
In 2007 a group from the Netherlands published a major series
using this technique [ 6 ] . An ePTFE mesh was incised, placed
around the stomal loop, and closed again by sutures forming a
short funnel. The results were promising; however, the observation period was only 6 weeks. An updated publication from
the same group with a median observation time of 30 months
revealed a recurrence rate of 37% [ 7 ] . Another study found
D. Berger (*)
Department of General Surgery , Stadtklinik ,
Balgerstrasse 50 , Baden-Baden 76532 , Germany
e-mail: d.berger@klinikum-mittelbaden.de
recurrences in 8 out of 11 patients [ 8 ] . Similarly LeBlanc et al.
abandoned this approach because of a fear of the potential
high failure rate, although few were seen [
from his own results using a variety of laparoscopic techniques
that laparoscopy provides only theoretical advantages [
McLemore et al. found two recurrences after mesh explantation in 19 patients [ 11 ] . Summarizing the results, it can be
concluded that the only major series that did not provide promising results used the keyhole technique, which is also supported by smaller studies. Furthermore other studies comprising
a small number of patients and incomplete or ill-de fi ned follow-up may reveal better results.
9 ] . Safadi concluded
10 ] .
Sugarbaker Technique
In 1985 Sugarbaker described the long-term results of seven
patients treated with a mesh placed intraperitoneally, covering the stoma site, with the fascial defect, and the stomal
loop [ 5 ] . Lateralizing the stomal loop between the abdominal
wall and the mesh for at least 5 cm is crucial. No recurrences
or any other complications have been detected. The laparoscopic adaption of that technique seems to be easy and consequently some series have been published. The recurrence
rates range between 0 and 33% [ 8, 9, 11, 12 ] . However, the
studies usually contain less than 20 patients. Our own experience with 41 patients treated laparoscopically according to
Sugarbaker between November 1999 and April 2004 which
have been consequently followed by clinical examinations
was published in 2007 [ 13 ] . Despite wide parietalization and
use of big meshes, the recurrence rate amounted to 20% after
a median follow-up of 24 months. The common problem of
the patients with a recurrence was a primarily lateral defect.
The recurrence occurred laterally as well.
So in summary the laparoscopic approach according to
Sugarbaker may be effective if the fascial defect is located medially but should be omitted in case of lateral defects. The studies
demonstrating acceptable results mainly contain small numbers
of patients and the quality of the follow-up is inconsistent or not
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_24, © Springer Science+Business Media London 2013
377
378 D. Berger
well documented. As for the keyhole technique there is only one
study with a reasonable number of patients demonstrating the
weak points of the Sugarbaker technique to our knowledge.
Sandwich Technique
When we have realized that the recurrence after the
Sugarbaker technique starts laterally, we decided to reinforce
the complete lateral part of the abdominal wall as an added
procedure. So a combination of the keyhole technique with
the Sugarbaker approach was developed. Basically the keyhole mesh should reinforce the lateral part, and a larger onlay
mesh will also cover the midline.
The technique follows well-known principles of the laparoscopic repair of incisional hernias. Usually the pneumoperitoneum is created using an open approach subcostally in the
right anterior axillary line. Three additional trocars at the level
of the umbilicus and in the right lower and left upper quadrant
will be needed in cases with an ostomy in the left lower quadrant. If there is an enterostomy in the right lower quadrant, we
would start in the left anterior axillary line. We always use a
30° laparoscope. The details of our technique are given in the
fi gures. Primarily a complete adhesiolysis of the abdominal
wall is performed not to miss any incisional defects. Figure 24.1
demonstrates the parastomal defect. Figure 24.2 shows the
opened space of Retzius. We prepare the prevesical space in
all cases in order to allow a major overlap of the lower midline
incision, which is utilized in almost all cases during the primary procedure. As shown in our publications most patients
not only have parastomal but also incisional hernias [ 13, 14 ] .
The ligamentum teres hepatis (Fig. 24.3 ) must be dissected to
provide fi rm fi xation of the upper edge of the mesh. A
15 × 15 cm mesh is incised in a keyhole fashion and placed
around the stomal loop as shown in Figs. 24.4 and 24.5 . The
central hole has a diameter of 1–1.5 cm. The incision is closed
by two transfascial sutures and tacks which allow the adjustment of the central hole to the diameter of the stomal loop
which may differ due to the amount of fatty tissue of the mesocolon. Figures 24.6 and 24.7 demonstrate the placement of the
mesh according to Sugarbaker before and after fi xation with
tacks. The stomal loop is well parietalized between the two
meshes, and the incision in the lower and upper abdominal
wall is covered due to the extensive dissection of the prevesical space and the ligamentum teres hepatis.
The sandwich technique requires meshes that will be
incorporated even after overlapping each other. So microporous products containing expanded polytetra fl uoroethylene
(ePTFE) should not be used. To our knowledge, no experimental data exists that examines the postoperative course
when covered meshes are placed with an overlap.
The availability of an open mesh structure without any coverage allowing overlap and incorporation as well as prevention
Fig. 24.1 Fascial defect of the parastomal hernia
Fig. 24.2 Opened prevesical space showing the symphysis and the
pubic bones
Fig. 24.3 The dissected ligamentum teres hepatis
37924 The Laparoscopic Repair of Parastomal Hernias
Fig. 24.4 The keyhole mesh is placed around the stomal loop showing
the two transfascial sutures
Fig. 24.5 Finally closed keyhole mesh
Fig. 24.7 Final intraperitoneal view of the sandwich technique
of intra-abdominal adhesions (Dynamesh ® ) was the inevitable
prerequisite of our technique. After a median observation time
of 12 months the fi rst 25 patients did not have any recurrences
[ 13 ] . The second publication summarizing 47 patients after a
median follow-up of 20 months described 1 recurrence [ 14 ] .
Two patients developed an early stenosis of the stomal loop at
the fascial level. These patients had predominantly subcutaneous prolapse which is usually located laterally, resulting in a
sharp kink at the fascial level and the keyhole mesh. A local
revision and shortening of the subcutaneous stomal loop solved
the problem. It must be pointed out that the laparoscopic treatment of a subcutaneous prolapse is very dif fi cult if not
impossible.
One abscess of the hernia sac occurred which healed after
VAC therapy. A deep wound infection after local revision
because of a stomal stenosis again healed despite involved
meshes! The total morbidity is extensively shown in the original publication and seems to be higher than in cases with incisional hernias. But the complication rate seems to be acceptable
with respect to the complexity of parastomal hernia repair.
According to our own data not yet published comprising
60 patients after the sandwich technique, which were treated
up to June 2009, the complication rate has remained low and
no further recurrence has been observed. The median observation time approaches 30 months. In two patients we had to
convert to an open procedure and another patient developed
stomal stenosis. The stenosis was also treated in the manner
described above.
Fig. 24.6 Sugarbaker mesh widely covering the stoma place and the
midline
Discussion
The parastomal hernia represents a common complication
after stoma formation. Despite the fact that most patients
with a clinically detectable hernia also suffer from symptoms
380 D. Berger
only a small number of patients will be treated surgically.
This may be explained by the high rate of recurrences and
further complications even in recent studies. However these
as well as former publications mainly suffer from low patient
numbers and unclear or not de fi ned observation techniques
and periods. The same fact passes for almost all studies dealing with the laparoscopic approach. Nevertheless the worst
results in terms of a high recurrence rate will be achieved by
the keyhole technique. The Sugarbaker technique may be
better but recurrence rates up to 20% are clearly too high.
Our experience proved the lateral part of the abdominal wall
as the weak point of the Sugarbaker technique.
Our experience also showed that 62 out of 66 patients
with a parastomal hernia also have an incisional hernia [
13 ] .
The stabilization of the lateral abdominal wall and the wide
coverage of the midline are best provided by the combination
of the keyhole and the Sugarbaker technique, the so-called
sandwich technique. The recurrence rate is low with an
acceptable morbidity which can be concluded from the own
cohort studies with a suf fi cient number of patients and adequate follow-up performed clinically [ 13, 14 ] .
The prerequisite of the sandwich technique is the availability
of a mesh allowing incorporation despite overlapping each
other. Microporous products cannot be used; meshes of pure
polypropylene or polyester should not have contact with the
bowel because of adhesions and fi stula [ 15 ] . Our experience
with a structure made by polyvinylidene fl uoride since 2004 has
shown no mesh-related complications in more than 600 patients
with primary and secondary ventral and parastomal hernias
(unpublished data). The subcutaneous prolapse remains a problem which cannot be addressed laparoscopically and causes
some asymmetry of the abdominal wall even after ideal reduction and stabilization of the parastomal hernia.
Very recently a meta-analysis allowed an insight in the real
future: the prophylaxis of parastomal hernia using a mesh at
the time of stoma formation [ 16 ] . Today it is absolutely clear
that prophylactic meshes can be effectively used in onlay, sublay, or intraperitoneal positions and dramatically reduce the
frequency of parastomal hernias. Until and if this idea will be
acceptable to place that kind of prophylaxis, the laparoscopic
sandwich technique should be considered as an effective treatment option of the inevitable hernia that develops.
Conclusion
After the formation of an ostomy hernias will be diagnosed in
up to 70% of the patients. Cases with a clinically obvious hernia usually suffer from impairing symptoms. The surgical therapy is mainly based on mesh augmentation of the abdominal
wall. Laparoscopically the meshes can be used according to
Sugarbaker, in a keyhole fashion, or combining both approaches
(sandwich technique). The best results by far can be achieved
by the sandwich technique. According to our own results, the
recurrence rate amounts to 3% with an acceptable complication
rate. The literature clearly shows that the keyhole approach will
be followed by a high recurrence rate. The same fact passes for
the Sugarbaker technique at least in our own published experience. The laparoscopically performed sandwich technique is a
surgically challenging but very effective procedure with results
which cannot be achieved with any other approach.
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