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Takedown of Enterocutaneous Fistula
strategy, it is therefore the gastrointestinal, rather than the abdominal wall, reconstruction that is staged.
Choice of Technique for Larger Abdominal Wall Defects
The precise technique to be used for reconstruction of larger abdominal wall defects in
patients with enteroatmospheric fistulation, or in whom an enterocutaneous fistula
coexists with a large incisional hernia, is determined by locally available expertise
and personal preference. These cases occur in small numbers, even in specialized
centers, and there are no randomized trials or even large cohort studies to allow an
adequately evidence-based approach to be developed. However, there are some
general principles that influence surgical decision making with regard to reconstruction of the largest abdominal defects in patients undergoing surgery for enterocutaneous fistulas. All abdominal wall reconstructions represent a further, major surgical
undertaking and should be performed only in patients who are deemed sufficiently
fit. Although polypropylene and other synthetic materials have proved to be inert
and inexpensive, making them ideally suited to incisional hernia repair, the fact that
the abdominal wall defect in a patient with an enterocutaneous fistula is intrinsically
contaminated at the outset makes synthetic material unsuitable for abdominal wall
reconstruction.
Reconstruction with Autologous Tissue
The use of autologous tissue for reconstructing the abdominal wall, after takedown of
an enterocutaneous fistula, has the advantage of using native tissue in a (often heavily)
contaminated field. The available techniques have been reviewed extensively
include separation of components,
37,47–49
cled
and free50and combinations of the 2,51with or without additional biolog-
46
as well a variety of thigh flaps, both pedi-
ical material to facilitate closure of the abdominal wall defect with the flap.
52
Of all of
41
and
the reported techniques, separation of components has probably been most widely
used in abdominal wall closure for patients with enterocutaneous fistulas. Separating
the rectus muscle from the posterior rectus sheath and detaching the external oblique
from the internal oblique generates up to 10 cm of additional abdominal wall at the
midabdomen and approximately 5 to 6 cm at the epigastrium and the suprapubic regions (where there is usually a smaller requirement for abdominal wall in reconstructive
surgery anyway). When undertaken bilaterally, separation of components may therefore generate up to 20 cm of additional abdominal wall, and this may allow all but the
biggest of defects to be closed.
Although this is an attractive option, and it is certainly simpler and better tolerated
than plastic surgical flaps taken from the thigh, it is not without problems when used
for patients who are undergoing gastrointestinal reconstruction. Wound complications
are common, and significant wound morbidity was reported in 24%, and incisional
hernia in 18.2%, of the 354 cases reported in the largest meta-analysis reported to
41
date.
Plastic surgical reconstruction was associated with even higher wound
morbidity (42%) and incisional hernia (29%). Separation of components may create
particular problems when the gastrointestinal reconstruction requires creation of
stomas through abdominal wall that has been weakened or distorted by the dissection
required for separation of the external and internal oblique muscles. It is unclear
whether this results in a significantly greater incidence of parastomal hernia, although
that seems likely.
Plastic surgical flaps are probably best reserved for large defects (>200 cm
patients. Pedicled flaps based on the lateral circumflex femoral artery, such as the
subtotal lateral thigh flap,
37
are technically demanding but allow virtually the entire
2
) in fit
1177
1178
Slade & Carlson
Fig. 12. Subtotal lateral thigh flap used to fill defect after fistula takedown.
abdominal wall (800 cm2) to be replaced. This flap is a myofasciocutaneous flap and
allows reconstruction of the abdominal wall skin as well as muscle, with a reasonable
cosmetic result (Figs. 12–14). The donor site usually requires covering with a split skin
graft taken from the contralateral thigh (Fig. 15). The complexity and high complication
rates associated with such procedures probably limit their applicability to specialized
centers and just a handful of suitable patients.
Reconstruction with Biological Implants
The concept underlying the use of biological materials when used to reconstruct the
abdominal wall after takedown of enterocutaneous fistula is that they are being put
into an operative field that is, at best, heavily contaminated and, at worse, dirty. A
detailed description of these materials is beyond the scope of this article, but, in general, they are based on collagen derived from porcine, bovine, or human sources. The
collagen may be derived from skin (dermis), gastrointestinal submucosa, or pericardium. The material is processed to ensure sterility, remove antigenicity, and may be
Fig. 13. Flap mobilized and ready to be placed into abdominal defect.
Takedown of Enterocutaneous Fistula
Fig. 14. Flap sutured into abdominal defect.
chemically cross-linked in an attempt to resist or delay enzymatic degradation. These
products are expensive and have not been subjected to randomized controlled trials in
this setting. There are no cohort studies specifically pertaining to their use in enterocutaneous fistula. A recent prospective study of a non–cross-linked porcine collagen
1179
Fig. 15. Cosmetic result of abdominal wall reconstruction and donor site from right thigh.
1180
Slade & Carlson
implant used to reinforce repair of contaminated abdominal hernia wounds reported a
recurrence rate of 28% at 2 years.
53
The key issue with the use of porcine dermal collagen in reconstructing the abdominal wall after enterocutaneous fistula is where to place the material. Biological
implants seem to work most effectively when interleaved between layers of vascularized host tissue, thus encouraging ingrowth of blood vessels and remodeling. They
may therefore be effective when used to support an abdominal wall closed by separation of components.
Although the material might be even more useful as a bridge in cases in which
separation of components leaves a sizable defect, the rate of mechanical failure of
the implant in this setting seems to be so high as to make it no more effective than
a (considerably less expensive) piece of polyglactin. Incisional herniation has been reported to occur in between 44% and 80% of such patients.
linked porcine dermal collagen material in direct contact with intestine has been
shown to be associated with a 41.7% incidence of refistulation,
53,54
Placement of cross-
23
which is clearly unacceptable. The bowel seems to become densely adherent to the implant in such
cases, making further attempts to reconstruct the gastrointestinal tract especially
challenging.
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Takedown of Enterocutaneous Fistula
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1183
Parastomal Hernia Repair
Nilay R. Shah, MD, MSa, Randall O. Craft, MDb,
a,
*
Kristi L. Harold,
KEYWORDS
Parastomal herniaSugarbaker techniqueKeyhole techniqueLaparoscopy
Outcomes
KEY POINTS
Parastomal hernia is an almost inevitable consequence of stoma formation. Most parasto-
mal hernia appears within 2 years of stoma formation.
Laparoscopic keyhole technique has higher rates of recurrence (34.6%) than laparoscopic
Sugarbaker technique (11.6%).
Overall, results of open and laparoscopic repair were similar in terms of morbidity and
mortality. Length of stay is shorter with laparoscopic procedure.
Prophylactic mesh placement during stoma formation lowers rates of parastomal
herniation.
INTRODUCTION
Parastomal hernia (PSH) is the protrusion of abdominal contents next to a stoma
through the abdominal wall defect created during ostomy formation. The incidence
varies widely, ranging from 0% to 48%, largely dependent on the type of enterostomy
created (Table 1).
inadequacy of physical examination in detecting early occurrences makes the true
incidence difficult to quantify. Although laparoscopic and trephine stoma formation
show a lower incidence of hernia formation, the studies published on these techniques
are small series with short follow-up (none longer than 1 year). Several classification
systems have been proposed but none are universally accepted (Table 2).
and colleagues
scan based on content of hernia sac (Table 3). However, the diagnosis can usually
be made by history, physical examination, digital examination of stoma, and CT scan.
MD
1–3
The lack of a uniform definition of what constitutes a PSH and the
4–6
7
proposed radiologic classification by computed tomography (CT)
Seo
Funding Sources: None.
Conflict of Interest: None.
a
Department of Surgery, Mayo Clinic Hospital, 5777 East Mayo Boulevard, MCSB SP 3-522 Gen
Surg, Phoenix, AZ 85054, USA;
MD Anderson Cancer Center, 2946 East Banner Gateway Drive, Gilbert, AZ 85234, USA
* Corresponding author.
E-mail address: Harold.Kristi@mayo.edu
Surg Clin N Am 93 (2013) 1185–1198
http://dx.doi.org/10.1016/j.suc.2013.06.011 surgical.theclinics.com
0039-6109/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
b
Plastic and Reconstructive Surgery, Division of Surgery, Banner
1186
Shah et al
Table 1
Incidence of parastomal hernias after enterostomies
Type of Enterostomy Incidence of Parastomal Hernias (%)
End colostomy 4–48
Loop colostomy 0–31
End ileostomy 1.8–28.3
Loop ileostomy 0–6
Laparoscopic stomal formation 0–6.7
Trephine stoma formation 6.7–12
Most hernias appear within 2 years of stoma formation.2Risk factors associated
with formation of PSHs are advanced age, technical failure, increased intraabdominal pressure, emphysema, obesity, malnutrition, steroid use, malignancy,
and wound infection.
1,8–11
However, the exact cause for PSH formation remains unknown. There has been some speculation of the loss of tensile strength caused by
a shift of the collagen ratio from mature type I collagen to immature type III collagen
during healing.
8,10
Most PSHs are asymptomatic and are managed nonoperatively.
However, 11% to 70% require surgical intervention because of obstruction or incarceration, prolapse, giant hernia, pain, bleeding, appliance leakage, or discomfort
from an ill-fitting appliance.
11,13
PSH REPAIR
Open Repair
Various procedures have been used for PSH repair, including primary repair, stoma
reversal, stoma relocation, and placement of prosthetic mesh. Primary fascial repair
is technically simple, avoids an additional laparotomy incision, and has low morbidity
but is associated with a reported 46% to 100% recurrence rate.
1,11
Stoma relocation
requires an additional laparotomy, resulting in three potential hernia sites, and is
12
Table 2
Classification of parastomal hernias
Rubin Devlin Gil and Szczepkowski
Type 1 Peritoneal hernia sac
through dilated
stomal canal
Type 2 Intrastomal hernia Subcutaneous hernia Parastomal hernia associated
Type 3 Subcutaneous prolapse Intrastomal hernia Large, isolated parastomal
Type 4 Pseudohernia Peristomal hernia with
Interstitial hernia with hernia
sac located between layers
of abdominal muscles
stomal prolapsed
Parastomal hernia without
coexisting cicatricial hernia
and without abdominal
wall deformation
with cicatricial hernia
without deformation of
abdominal wall
hernia without coexisting
cicatricial hernia with
abdominal wall deformity
Large parastomal hernias
with coexisting cicatricial
hernia with abdominal
wall deformity
Parastomal Hernia Repair
Table 3
Radiologic classification of parastomal hernia
Type Content of Hernia Sac
0 Peritoneum follows the wall of the bowel forming the stoma, with no formation
of a sac
Ia Bowel forming the colostomy with a sac <5 cm
Ib Bowel forming the colostomy with a sac >5 cm
II Sac containing omentum
III Intestinal loop other than the bowel forming the stoma
1187
associated with a recurrence rate of up to 24% to 86%.
22.6% to 88% have been reported for primary fascial repair and stomal relocation.
5,6
Overall complication rates of
5,11
Prosthetic mesh repair of PSHs can be onlay, retromuscular, or intraperitoneal. In
1985, Sugarbaker was the first to describe the intraperitoneal mesh repair of a
14
His technique involved securing the mesh over the entire fascial defect circum-
PSH.
ferentially except laterally to create a mesh flap valve around the stoma (Fig. 1). This
prevented herniation and contact with the stoma bud, theoretically reducing infection.
In his published series of seven patients, there were no reported recurrences or complications after 4 to 7 years follow-up. In the Keyhole technique, a 2- to 3-cm “keyhole”
cut-out is made to surround the ostomy while covering the entire hernia defect
(Fig. 2).
keyhole is made and a risk of recurrence if the hole is larger. In a review of reported
series, overall morbidity was 22.2%. Recurrence rate was 9.4%.
15–18
However, there is a risk of obstructing the enterostomy if a smaller
19
Laparoscopic Repair
The advent of laparoscopic surgery in ventral hernia repair has led to many benefits
including less pain, shorter hospital stay, and faster recovery. Laparoscopic repair
of PSH has the advantages of greater mesh overlap and transabdominal fixation while
avoiding the creation of new hernia sites. Current described approaches for laparoscopic PSH repair include a modified Sugarbaker technique, a keyhole technique,
and a “sandwich” technique, which incorporates elements of both.
Our clinical experience mirrors the current literature suggesting that the use of a
solid piece of mesh versus a cut piece of mesh results in a lower hernia recurrence
and a shorter operative time.
Fig. 1. Sugarbaker repair. (From Huguet KL, Harol KL. Laparoscopic parastomal hernia
repair. Oper Tech Gen Surg 2007;9(3):119; with permission.)