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226
Fig. 22.4 Laparoscopic
measure the hernia
defect
K. He and Q. Yao
Fig. 22.5 Laparoscopic Keyhole technique Fig. 22.6 Laparoscopic Sugarbaker technique
Sugarbaker technique not only for paracolostomal hernia (PCSH), but also for
paraileostomal hernia (PISH) caused by
ileal conduit (Fig.22.7).
– Sandwich Technique
◦ D. Berger reported “Sandwich” tech-
nique with two pieces of DynameshIPOM (FEG-Textiltechnik, Aachen,
Germany), a type of large pore-size
anti- adhesion mesh, which was combined with “Keyhole” technique and
“Sugarbaker” technique in 2007 [14].
Fig. 22.7 Laparoscopic Sugarbaker technique for PISH
after ileal conduit
– Lap-re-Do Technique
◦ Step 1. Laparoscopic approach. After
adhesiolysis, reducing the hernia contents and measuring the hernia defect,
we continue to dissociate the stoma
bowel cautiously until closing to the
anterior abdominal dermal or subcuta-
22 Parastomal Hernia
227
neous layer as possible. The relationships and the length ratio between the
colostomal bowel and its mesentery
should be also observed, which will
indicate to apply Lap-re-Do Keyhole
with a limitation of stomal bowel length
or Lap-re-Do Sugarbaker technique
with abundant stomal bowel length to
repair hernia defect with an antiadhesion prosthesis afterwards.
◦ Step 2. Open approach. Then, we trans-
fer to make a round incision alongside the
original stoma to pull through the stoma
bowel (Fig. 22.8), which is sealed by a
sterilized glove and deligated at once to
prevent contamination (Fig.22.9).
After re-sterilizing the stoma operative eld, if the Keyhole technique
would be performed, we shall utilize the
Dynamesh-IPST mesh (FEGTextiltechnik, Aachen, Germany) with a
pre-shaped and elastic 3-D funnel
device in the center of it which the stomal bowel can be pulled through. We
sew up the stomal bowel to the preshaped and elastic 3-D funnel device by
3–0 anti-bacteria Vicryl (Ethicon, New
Jersey, USA). Then we put the mesh
into the abdominal cavity with its polypropylene side to abdominal wall and
the PVDF side to viscera, and sew up to
close hernia ring with Surgilon
(Covidien, Manseld, USA), a type of
nonabsorbable stitches, to an appropriate size to let stomal bowel pass through
without entrapment (Fig.22.10). But if
Sugarbaker technique is applied to
repair PCSH, during this operative step
Fig. 22.8 Lap-re-Do Technique: Round incision along-
side the stoma
Fig. 22.9 Lap-re-Do
Technique: Sealing up
the stoma bowel
Fig. 22.10 Lap-re-Do Technique: Sew up the hernia ring
228
K. He and Q. Yao
we only need to deal with the hernia
defect just like we have introduced
above and the anti-adhesion prosthesis
would be put into the abdominal cavity
through the 10-mm trocar.
◦ Step 3. Laparoscopic approach. After
unfolding the transparent or semi- transparent mesh atly and adjust its position
around the stoma bowel in abdominal
cavity, we x the Dynamesh-IPST mesh
as a Keyhole technique, or an antiadhesion prosthesis as Sugarbaker technique to the abdominal wall with
ProTack (Covidien, Manseld, MA,
USA) or Absorbable screws (Ethicon,
New Jersey, USA) (Figs. 22.11 and
22.12). Drainage is recommended with
potential risk of unrecognized enterotomy when a serious adhesiolysis is performed during the operation.
◦ Step 4. Open approach. Finally, we
remove the hernia sac, reduce the subcutaneous space and suture the stomal
bowel to abdominal wall with 3–0 antibacteria Vicryl stitches (Ethicon, New
Jersey, USA) interruptedly, sometimes
even with local vacuum sealing drainage to prevent potential parastomal
seroma or infection, resect and cut off
the redundant stoma bowel, rebuild a
stoma in situ (Fig.22.13), We also suggest our patients to be wrapped up with
a belt around the lower abdominal wall
for at least 3months postoperatively.
Fig. 22.11 Lap-re-Do: Keyhole technique
Fig. 22.12 Lap-re-Do: Sugarbaker technique
22 Parastomal Hernia
Fig. 22.13 Lap-re-Do: Re-colostomy in situ
229
• Postoperative care
– The patient can drink water 6 h after the
operation, have full liquid diet on the rst
postoperative day, and eat semi-liquid diet
after postoperative exhaust.
– The rebuilt stoma in situ should be observed
very carefully to evaluate its blood supply
after operation.
– The amount and nature of the uid drain-
age should be recorded and observed every
day postoperatively.
– Postoperative analgesia treatments are
applied in all the patients to relieve the pain
caused by patching mesh.
– Postoperative early ambulation is recom-
mended to all the patients to prevent deep
vein thrombosis and pneumonia.
• Postoperative complications
– Intraoperative Complications
◦ Intestinal injuries and bleeding are sig-
nicant events that may occur during
the dissection of the intestine or adhesiolysis during any bowel surgery.
Incidence of Intraoperative intestinal
injuries is approximately 1–3% [12].
The management of a recognized enterotomy is somewhat controversial; a part
of surgeons will terminate the hernia
repair procedure and only repair the
injury either laparoscopically or by a
conversion to the open operation [13].
More recently, we agree with the reports
indicating that the repair of the recog-
nized intestinal injury and completion
of the intended hernia repair may be
safe because of application of the antiadhesion prosthesis without e-PTFE
[14]. Meanwhile we also recommend
applying the Harmonic Scalpel to lyse
the omentum adhesions to prevent
bleeding.
– Postoperative Complications
◦ Unrecognized enterotomy is a serious
complication that occurs in less than 1%
patients [15]. This is often caused by a
traction injury from the grasping instruments or a burn from the use of an
energy source to lyse the adhesions during the procedures.
◦ Stoma-related complications including
ischemia, collapse, and stenosis of the
stoma bowel have been observed in our
series of Lap-re-Do technique. We dealt
with all the stoma-related complications
without re-operation, but the surgeon
who may apply the Lap-re-Do technique should pay attention to the procedure of re-ostomy and care must be
taken to avoid injury of stoma bowel
and its mesentery.
◦ Ileus includes adhesive intestinal
obstruction and stoma obstruction. It is
one of the most reported postoperative
complications in nearly every literature
about PSH with an incidence of approximately 6.3% [4]. Most of ileus can be
230
K. He and Q. Yao
healed up with conservative treatment
without re-operation.
◦ Infection is another kind of common
postoperative complication including
mesh infection, wound infection, pneumonia, and urinary infection. Mesh
infection in the laparoscopic approach
was reported in 3.7% lower than in open
hernia repair [16].
◦ Seroma There has been a series of
patients that were evaluated by ultrasonic
study found the incidence of seroma is
100% because the hernia sac is not
removed and its peritoneal membrane
surface will secrete the uid which can
be contained by the prosthetic mesh [17].
If the seroma occurs, a puncture under
ultrasonic location is recommended. We
designed the Lap-re-Do technique to
remove the hernia sac even with local
subcutaneous vacuum sealing drainage
to prevent potential parastomal seroma.
22.3 Summary
It is well known that most ostomates face sensitive
physical, social, and psychological problems, and
severe stoma-related issues often impair their
quality of life. The parastomal hernia, known to be
a common complication, often causes stoma care
problems, such as leakage and skin irritation, and
can lead to rare but severe complications including
obstruction, bowel incarceration, and perforation.
Obesity, chronic lung disease, type II DM,
advancing age, malnutrition, renal failure, malignancy, steroid treatment, jaundice, radiotherapy,
chemotherapy, and oral anticoagulant use are
considered to be patient-related factors that
increase the risk of developing an incisional hernia [18]. In addition to these factors, the site of
stoma placement, the peritoneal route used for
colostomy creation (extraperitoneal or transperitoneal) and the size of the fascial opening are
reported to be risk factors for parastomal hernia
development [19].
A variety of open and laparoscopic approaches
to repair parastomal hernia with mesh have been
reported in the past 50 years. Open approaches
include onlay, sublay, and IPOM technique, and
laparoscopic approaches include common repairs
like Keyhole or Sugarbaker technique and case
report as Sandwich, Double Patch, and Scroll
technique. The recurrence of different approaches
with a range of 0–62.5% and complications can
be referred from many literatures and metaanalysis of PSHs [20–34] (Table22.1). We have
performed Laparoscopic Sugarbaker technique
on 11 PISH patients after ileal conduit since April
2005, and no recurrence occurred afterwards.
Table 22.1 Follow-up of PSH repairs (No>10)
Study Year No of repairs Technique Recurrence (%) Infection (%) Follow-up (months) (mean)
Luning 2009 16 Open onlay 19 6.2 6–110 (33)
Valdivia 2008 25 Open onlay 8 8 8–24 (12)
de Ruiter 2005 46 Open onlay 15.9 6.6 12–156 (60)
Steele 2003 58 Open onlay 26.0 3.4 0.2–139 (50.6)
Geisler 2003 16 Open onlay 62.5 12.5 2–161 (39)
Egun 2002 10 Open sublay 0 20 22–69 (54)
Sprundel 2005 15 Open IPOM 13.3 0 5–52 (29)
Stelzner 2004 20 Open IPOM 15 5 3–84 (42)
Mizrahi 2011 29 Keyhole 46.4 3.4 12–53 (30)
Hansson 2009 54 Keyhole 37 1.8 12–72 (36)
Pastor 2009 12 Keyhole/sugarbaker 33.3 16.6 (13.9)
Muysoms 2008 24 Keyhole/sugarbaker 41.7 0 4–54 (21.2)
Berger 2007 41 Sugarbaker 19.5 4.5 3–72 (24)
47 Sandwich 2.1 2.1 (20)
Craft 2007 21 Keyhole/sugarbaker 4.7 4.8 3–36 (14)
Mancini 2005 25 Sugarbaker 4.0 4.0 2–38 (19)
LeBlanc 2005 12 Keyhole/sugarbaker 8.3 0 3–39 (20)
22 Parastomal Hernia
231
We have performed Lap-re-Do technique on
102 PCSH patients from May 2009 to June 2015,
including 93 primary PCSHs and 9 recurrent
PCSHs. The mean operating time was 113min
and the mean length of postoperative hospital
stay was 8 days. 16 patients were observed as
recurrence (rate ≈ 15.7%) during a mean
follow- up period of 39months (range from 6 to
79). According to the follow-up, the PCSH
patients with BMI over 26 run an obviously
higher risk of recurrence of 31.8% postoperatively than whose BMI under 26 with a recurrence of only 1.8%. Different postoperative
complications were observed in detailed on 21
patients in hospital and 18 patients after hospital
discharge, including stoma-related complications
on 15 patients, ileus and stoma obstruction on 19
patients in all, and 5 for others. Re-operation had
to be performed on 2 patients because unrecognized enterotomy and mesh infection, and no
patients died of procedure-related complications
(Table22.2).
Key Points
• Parastomal hernia is a difcult problem for sur-
geons to deal with because it is a special type of
dynamic incisional hernia with stoma bowel as
its hernia content, and there is lack of evidence
on the ideal technique for stoma formation or
surgical procedure for symptomatic parastomal
hernias. Herein, large prospective controlled
multicenter trials are required to compare dif-
ferent surgical techniques of laparoscopic para-
stomal hernia repair in reducing the
postoperative complications and recurrence.
• Future research needs to address the patho-
genesis of parastomal hernia formation, as
until we have fully understood the mechanism
of its formation, direct prevention, and treat-
ment will always be unsatisfactory.
• Laparoscopic Sugarbaker technique has a
good result on dealing with PISH patients
after ileal conduit and appears to be superior
to the “Keyhole” technique on PCSHs.
• “Lap-re-Do” technique is easy for surgeons to
learn and handle according to our introduc-
tions and graphical representation. The sum-
marized key-points of “Lap-re-Do” technique
Table 22.2 Follow-up of Lap-re-Do
Series (n=102)
Follow-up (mon) 39 (6~79)
Operating time (min) 113 (60~185)
Postoperative hospital stay (day) 6.5 (3, 66)
Hospitalized complications
Re-ostomy complications 9
Peristomal abscess
Parastomal seroma
Stoma ischemia
Others
Ileus/stoma obstruction 10
Others 4
Unrecognized enterotomy 1
Patients with no complications (rate) 81 (79.41%)
Discharged complications
Ileus 9
Stoma-related complications
Peristomal abscess
Colostomy stenosis
Stoma ischemia
Parastomal stula
Others 3
Patients with no complications (rate) 84 (82.35%)
Recurrence(rate)
Absorbable prosthesis(1)
Nonabsorbable prosthesis (101 cases) 15 (14.85%)
Comparing by BMI
BMI≥26 (44 cases)
BMI<26 (57 cases)
Different Lap-re-Do Types
Type A(32 cases)
Type B(52 cases)
Type C(17 cases)
a
Type A: “Lap-re-Do” Keyhole technique with slow-
absorbable stitches “PDS-II” to close the hernia ring;
Type B: “Lap-re-Do” Keyhole technique with nonabsorbable stitches “Surgilon” to close the hernia ring; Type C:
“‘Lap-re-Do” Sugarbaker technique with nonabsorbable
stitches “Surgilon” to close the hernia ring
a
1
3
3
2
6
3
1
1
1
16 (15.69%)
1 (100%)
14 (31.82%)
1 (1.75%)
8 (25%)
4 (11.5%)
1 (5.9%)
includes sewing up hernia defect with nonabsorbable stitches, repairing with no e-PTFE
prosthesis, operating in detailed with aseptic
concept, and shortening the length of time
when the stoma of colon once being open.
• Lap-re-Do technique can be considered as
another clinical choice for primary and recurrent PCSH therapy, especially on the patients
with BMI under 26, but the open approach of
Lap-re-Do technique to rebuild stomal area in
situ shall be improved step by step to reduce
the incidence of stoma-related complications.
232
K. He and Q. Yao
References
1. Pringle W, Swan E. Continuing care after discharge from hospital for stoma patients. Br J Nurs.
2001;10:1275–88.
2. Turnbull GB.Ostomy statistics: the $64,000 question.
Ostomy Wound Manage. 2003;49:22–3.
3. Brown H, Randle J.Living with a stoma: a review of
the literature. J Clin Nurs. 2005;14:74–81.
4. Hansson BME, de Hingh IH, Bleichrodt
RP. Laparoscopic parastomal hernia repair: pitfalls and complications. Hernia Repair Sequelae.
2010;3:451–5.
5. Moreno-Matias J, Serra-Aracil X, et al. The prevalence of parastomal hernia after formation of an end
colostomy. A new clinic-radiological classication.
Color Dis. 2009;11:173–7.
6. Hotouras A, Murphy J, Thaha M, Chan C.The persistent challenge of parastomal herniation: a review
of the literature and future developments. Color Dis.
2013;15:202–14.
7. Halabi WJ, Jafari MD, Carmichael JC, et al.
Laparoscopic versus open repair of parastomal hernias: an ACS-NSQIP analysis of short-term outcomes.
Surg Endosc. 2013;27:4067–72.
8. Helgstrand F, et al. Risk of morbidity, mortality, and
recurrence after parastomal hernia repair: a nationwide study. Dis Colon Rectum. 2013;56:1265–72.
9. Wijeyekoon SP, Gurusamy K, El-Gendy K, Chan
CL. Prevention of parastomal herniation with biologic/composite prosthetic mesh: a systematic review
and meta-analysis of randomized controlled trials. J
Am Coll Surg. 2010;211:637–45.
10. Shabbir J, Chaudhary BN, Dawson R. A systematic
review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia
formation. Color Dis. 2011;14:931–6.
11. Lee L, Saleem A, Landry T, etal. Cost effectiveness
of mesh prophylaxis to prevent parastomal hernia in
patients undergoing permanent colostomy for rectal
cancer. J Am Coll Surg. 2014;218:82–91.
12. Hansson BME, van Nieuwenhoven EJ, Bleichrodt
RP.Promising new technique in the repair of parastomal hernia. Surg Endosc. 2003;17:1789–91.
13. Sugarbaker PH. Peritoneal approach to prosthetic
mesh repair of paraostomy hernias. Ann Surg.
1985;201:344–6.
14. Berger D, Bientzle M.Laparoscopic repair of parastomal hernias: a single surgeon’s experience in 66
patients. Dis Colon Rectum. 2007;50:1668–73.
15. LeBlanc KA, Whitaker JM, Bellanger DE, et al.
Laparoscopic incisional and ventral hernioplasty: lessons learned from 200 patients. Hernia. 2003;7:378–82.
16. Heniford TB, Park A, Ramshaw BJ, etal. Laparoscopic
ventral and incisional hernia repair in 407 patients. J
Am Coll Surg. 2000;190:645–50.
17. Berger D, Bientzle M, Muller A.Postoperative complications after laparoscopic incisional hernia repair.
Surg Endosc. 2002;16:1720–3.
18. LeBlanc KA, Elieson MJ, Corder JM 3rd. Enterotomy
and mortality rates of laparoscopic incisional and
ventral hernia repair: a review of the literature. JSLS.
2007;11:408–14.
19. Pierce RA, Spitler JA, Frisella MM, et al. Pooled
data analysis of laparoscopic vs. open ventral hernia
repair: 14 years of patient data accrual. Surg Endosc.
2007;21:378–86.
20. Susmallian S, Gewurtz G, Ezri T, etal. Seroma after
laparoscopic repair of hernia with ePTFE patch: is it
really a complication? Hernia. 2001;5:139–41.
21. Pilgrim CH, McIntyre R, Bailey M. Prospective
audit of parastomal hernia: prevalence and associated
comorbidities. Dis Colon Rectum. 2010;53:71–6.
22. Funahashi K, Suzuki K, Nagashima Y, etal. Risk factors for parastomal hernia in Japanese patients with
permanent colostomy. Surg Today. 2014;44:1465–9.
23. Luning TH, Spillenaar-Bilgen EJ.Parastomal hernia:
complications of extra-peritoneal onlay mesh placement. Hernia. 2009;13:487–90.
24. Valdivia G, Guerrero TS, Laurrabaquio
HV.Parastomal hernia-repair using mesh and an open
technique. World J Surg. 2008;32:465–70.
25. Ruiter PD, Bijnen AB.Ring-reinforced prosthesis for
paracolostomy hernia. Dig Surg. 2005;22:152–6.
26. Steele SR, Lee P, Martin MJ, etal. Is parastomal hernia repair with polypropylene mesh safe? Am J Surg.
2003;185:436–40.
27. Geisler DJ, Reilly JC, Vaughan SG, etal. Safety and
outcome of use of nonabsorbable mesh for repair of
fascial defects in the presence of open bowel. Dis
Colon Rectum. 2003;46:1118–23.
28. Egun A, Hill J, MacLennan I, et al. Preperitoneal
approach to parastomal hernia with coexistent large
incisional hernia. Color Dis. 2002;4:132–4.
29. Sprundel ST, Hoop AG. Modied technique for
parastomal hernia repair in patients with intractable
stoma-care problems. Color Dis. 2005;7:445–9.
30. Stelzner S, Hellmich G, Ludwig K. Repair of paracolostomy hernias with a prosthetic mesh in the
intraperitoneal onlay position: modied Sugarbaker
technique. Dis Colon Rectum. 2004;47:185–91.
31. Mizrahi H, Bhattacharya P, Parker MC.Laparoscopic
slit mesh repair of parastomal hernia using a designated mesh: long-term results. Surg Endosc.
2012;26:267–70.
32. Hansson BM, Bleichrodt RP, de Hingh
IH. Laparoscopic parastomal hernia repair using a
keyhole technique results in a high recurrence rate.
Surg Endosc. 2009;23:1456–9.
33. Pastor DM, Pauli EM, Koltun WA, etal. Parastomal
hernia repair: a single center experience. JSLS.
2009;13:170–5.
34. Muysoms EE, Hauters PJ, Van Nieuwenhove Y, etal.
Laparoscopic repair of parastomal hernias: a multicentre retrospective review and shift in technique.
Acta Chir Belg. 2008;108:400–4.
Muscle–Aponeurotic Plication
Associated withDermolipectomy
intheTreatment ofVentral Hernias
andDiastasis Recti: AFunctional
andAesthetic Approach
MarcoAurelioFaria-Correa
23
23.1 Introduction
In the treatment of ventral hernias and diastasis
recti, a functional and an aesthetic approach
should be considered. The abdominal wall may
be affected by pregnancies, weight variation, and
previous abdominal surgical procedures [1–5].
The weakening of the muscle–aponeurotic layer
is attributed to a congenital condition related to
the ratio of collagen type I and III in the composition of the aponeurosis. It has been shown that
aponeuroses with a high concentration of collagen type III are weaker than those with a higher
number of type I ber [6]. Also, there is a change
in the relation of the rate of collagen types to the
aging process, with an increasing number of collagen types III compared with type I [7]. The
quality of the extracellular matrix of the skin,
aponeurosis, and muscle has similarities in the
same individual [8], which is why there is a
straight relationship between the muscle–aponeurotic deformity and the excess skin of the
abdomen. Patients presenting with a large amount
of excess skin have more complex muscle–aponeurotic deformities [6].
Based on a representative number of more
than 2560 patients, some with up to 20 years’
follow-up presenting with successful results
(Figs.23.1, 23.2, 23.3, and 23.4) and a series of
182 secondary surgeries for repairing unsuccessful cases (Figs.23.5 and 23.6), we present a study
of our personal clinical experience. We also present a bibliographic review of the efcacy and
durability of muscle–aponeurotic plication using
various methods of plication with different suture
materials, including absorbable and nonabsorbable [9, 10]. The long-term evaluation was
done with the use of clinical examination, in
addition to abdominal wall CT and linear ultrasound [10–12]. Trans-operative ndings in secondary cases were also analyzed, discussing the
type of suture material and stitching technique
used, in addition to the reason for failure.
23.2 Materials andMethods
During the last 30years, we have been treating
the small, medium and large cosmetic and functional abdominal wall deformities such as
abdominal lipodystrophies associated with dias-
M. A. Faria-Correa (*)
Dr Marco Faria Correa Plastic Surgery Pte Ltd,
Singapore, Singapore
e-mail: admin@drmarco.com, drmarco@drmarco.com
© Springer Nature India Private Limited 2020
P. Chowbey, D. Lomanto (eds.), Techniques of Abdominal Wall Hernia Repair,
https://doi.org/10.1007/978-81-322-3944-4_23
tasis recti, and with umbilical, ventral, and
hernias.
Our experience is approximately 2560 cases
divided up as follows:
233
234
ab
ab
M. A. Faria Correa
c
Fig. 23.1 Example of cosmetic abdominoplasty(lower
abdomen + rectus plication). (a) Before and after
3months—scar still visible. (b, c) After 3years, we can
observe that the scars are already fading and the functional and cosmetic results achieved are still present
Fig. 23.2 (a) Lower abdominal dermolipectomy drawing. (b) Showing the full ap of skin removed. (c) Before and
after 3years, scar results
ab
cd
23 Muscle–Aponeurotic Plication Associated withDermolipectomy intheTreatment ofVentral Hernias…
235
Fig. 18.2 (continued)
Fig. 23.3 Abdominoplasty
with plication performed
together with bilateral breast
lifting. (a, c) Pre-operatively.
(b, d) Post-operatively 10
months
c