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J.A. Cavallo et al.
system based on characteristics of both the patient and the hernia defect
[ 29 ] . Grade 1 (low-risk) ventral hernias are clean, uncontaminated
surgical sites of patients without a history of comorbidities or wound
infection. The VHWG recommends that patient factors and the clinical
judgment of the surgeon should be weighed in the choice of appropriate
repair materials for grade 1 ventral hernias. Grade 2 (comorbid) ventral
hernias are clean, uncontaminated surgical sites of patients with
comorbidities that increase the risk for surgical-site infection. The
VHWG notes that the relative contribution of different patient
comorbidities (i.e., diabetes mellitus, obesity) to the risk of a surgical
site occurrence is a matter of consideration and debate. Therefore, the
VHWG advises that surgeons must continue to rely on their clinical
judgment for the identi fi cation and appropriate treatment of grade 2
ventral hernias until comparative data is available. The VHWG suggests
that patients with comorbidities associated with an increased risk of
surgical site infection may bene fi t from reinforcement of grade 2 ventral
hernias with biologic scaffolds rather than synthetic repair materials.
However, given the high cost of biologic scaffolds (Table 44.1 ) and the
insuf fi cient evidence that biologic scaffolds confer clinical bene fi t over
synthetic reinforcement materials for the repair of clean, uncontaminated
hernia defects [ 30 ] , it is dif fi cult to justify routine use of biologic
scaffolds for grade 1 or grade 2 ventral hernias. Grade 3 (contaminated)
ventral hernias are contaminated or potentially contaminated surgical
sites, including surgical sites in proximity to a stoma or a violation of
the gastrointestinal tract, or with a prior history of infection. Grade 4
(infected) ventral hernias are surgical sites with active infection, infected
foreign body, or septic dehiscence. Based on level A and B evidence,
the VHWG contraindicates the use of synthetic reinforcement materials
and instead advocates the use of biologic scaffold reinforcement for
grade 3 and 4 ventral hernias. Twelve-month interim results of the
RICH trial demonstrate safe, de fi nitive, single-stage reconstruction
using Strattice™ Reconstructive Tissue Matrix for 80% of studied
contaminated and infected ventral incisional hernias, further reinforcing
this VHWG recommendation [ 31 ] . It should be noted, however, that a
recent warning issued by the FDA to the study sponsors cautions
against the as-yet unapproved use of Strattice™ Reconstructive Tissue
Matrix for the reinforcement of contaminated or infected soft tissue
repair sites. [ 32 ] . Level B evidence supports the reduction of bioburden
prior to reinforcement material placement and de fi nitive repair of
infected defects [ 29, 33 ] . A delayed approach to repair should be
considered in the setting of gross, uncontrolled contamination of the
surgical site.
499
44. Biologic Mesh: When and Why—A Critical Appraisal
Prophylaxis for Parastomal Hernias
Parastomal hernias, or incisional hernias at the site of a stoma, are
a frequent and highly morbid complication of stoma formation. The
incidence of parastomal hernia is as high as 48% [
34 ] , and as many as
30% of parastomal hernias require surgical intervention for pain, bowel
obstruction, or fi stulation [ 35 ] . Recurrence rates for surgical repair of
parastomal hernias range between 30 and 76% [ 36 ] . Attention has
therefore been focused on parastomal hernia prevention. Strong
evidence supports the prophylactic reinforcement of stomas with
prosthetic mesh to signi fi cantly reduce the incidence of parastomal
herniation [ 37– 40 ] . Prophylactic reinforcement of stomal sites using
biologic or composite reinforcement materials at the time of stoma
creation is associated with a 77% relative risk reduction in the incidence
of parastomal herniation compared to conventional stoma formation
[ 36 ] . Given concern for adhesion, erosion, fi stulation, and mesh
infection with synthetic material reinforcement in close proximity to
the bowel, biologic scaffolds have been favored for both parastomal
hernia prophylaxis and repair. However, given similar rates of recurrence
and complications associated with the use of both synthetic and biologic
scaffolds for parastomal hernia repair, some surgeons argue that
insuf fi cient evidence exists to justify the preferred use of expensive
biologic scaffolds [ 41 ] .
Bridging Abdominal Wall Defects
Reinforcement of soft tissue defects with repair material without
primary closure of the fascial layer, otherwise referred to as the bridging
of soft tissue defects, is strongly discouraged in ventral hernia repair.
Bridging ventral incisional hernias with biologic scaffolds without
reducing the size and the overdue tension of the fascial defect has been
associated with an 80% rate of hernia recurrence [ 42, 43 ] . Abdominal
wall component separation to approximate the fascial edges of the defect
for primary closure with material reinforcement of the repair is an
acceptable alternative with more favorable recurrence rates (0–20%)
compared to bridging defects with repair material [ 42, 44, 45 ] .
It should be emphasized that characterization studies and clinical
trials evaluating the comparative effectiveness of available biologic
500
J.A. Cavallo et al.
scaffolds in ventral hernia repair are limited. Further comparative
investigation is warranted to inform surgeon selection of appropriate
biologic scaffold materials for different clinical circumstances.
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Frisella MM, Matthews BD. Early biocompatibility of crosslinked and non-crosslinked
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19. Deeken CR, Melman L, Jenkins ED, Greco SC, Frisella MM, Matthews BD. Histologic
and biomechanical evaluation of crosslinked and non-crosslinked biologic meshes in a
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880–8.
20. Wake MC, Patrick Jr CW, Mikos AG. Pore morphology effects on the fi brovascular
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BT. Assessment of adhesion formation to intra-abdominal polypropylene mesh and
polytetra fl uoroethylene mesh. J Surg Res. 2003;114(2):126–32.
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Part IX
Other Hernias
507
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_45,
© Springer Science+Business Media New York 2013
45. Parastomal Hernia Repair: Latest
Updates
Chee-Chee H. Stucky and Kristi L. Harold
Creation of an ostomy is a widely performed surgical procedure.
Enterostomies and colostomies are frequently formed as temporary or
permanent fecal diversions in the setting of in fl ammatory bowel disease,
carcinoma, trauma, or incontinence. Ileal conduits are also common
urinary diversion stomas formed for the treatment of urogenital diseases
including carcinoma and urinary incontinence. All of these stoma
variations have the potential for hernia development through the fascial
defect created in the abdominal wall at the time of formation. In fact,
parastomal hernias are considered the most common late complication of
stoma formation and typically occur within the fi rst 2 years following
creation [ 1– 3 ] . The risk of occurrence also increases with time [ 4, 5 ] .
The incidence of parastomal hernias ranges between 30 and 50%;
however, with increasing use of computed tomography imaging, detection
of asymptomatic parastomal hernias is increasing [ 2, 6, 7 ] . Comorbidities
predisposing patients to poor fascial integrity and increased intra-
abdominal pressure are the main risk factors associated with parastomal
hernia formation. These include older age, obesity, emphysema (chronic
cough), steroid use, malignancy, malnutrition, and wound infection [ 5,
8– 10 ] . Groups have also suggested that the type of stoma in fl uences the
incidence of parastomal hernia with paracolostomy hernias thought to be
more common than paraileostomy hernias due to larger fascial defects.
Reports on this topic demonstrate mixed results [ 11 ] .
The majority of patients (up to 70%) with parastomal hernias will not
require surgical intervention [ 1 ] . Nonoperative management includes
weight loss, abdominal binders, hernia support belts, and fl exible, low-
pro fi le (or fl angeless) pouching systems which may be more easily applied
in the setting of the hernia [ 10, 12 ] . Surgical intervention is indicated when
secondary complications arise such as obstruction, pain, bleeding, and
508
C.-C.H. Stucky and K.L. Harold
poorly fi tting stoma appliances resulting in skin breakdown secondary to
leakage of urine or intestinal contents. Stomal prolapse is often confused
with parastomal herniation; however, this situation is less likely to result
in functional compromise and therefore should be distinguished from
herniation [
3 ] . Parastomal hernia repair techniques include open suture
repair of the fascial defect, stoma relocation to the contralateral side of
the abdominal wall, and, more recently, reinforcement of the fascia with
mesh either in an open or laparoscopic fashion. This chapter reviews
the various methods of parastomal hernia repair as well as describes the
latest updates regarding these techniques.
Open Repair
The most de fi nitive method in repairing parastomal hernias is reversal
of the stoma. Unfortunately, this is not always a feasible option. Therefore,
many other methods have been described with variable success. A simple
and local option is primary fascial repair of the parastomal defect. While
this approach is quick and easy to perform, the risk of hernia recurrence
is quite high with reports ranging from 46 to 100% [ 13, 14 ] .
Relocating the stoma to the contralateral side of the abdominal wall
has been considered more successful than primary repair in terms of
hernia recurrence. Studies have demonstrated recurrence rates of
30–50%; however, this technique by de fi nition results in multiple sites
for potential hernia formation including the original stoma defect, the
new stoma defect, and the laparotomy incision used to relocate the stoma
[ 14 ] . Therefore, this method is not considered an ideal option for
treatment of parastomal hernias.
More de fi nitive management of these hernias has been established
with the use of prosthetic mesh reinforcement as a tension-free repair.
This may be done with either an onlay, sublay, or intraperitoneal
approach. The latter approach has been shown to have a low recurrence
rate of approximately 11% likely due to adequate mesh overlap on the
abdominal fascia [ 2 ] . However, this technique requires a laparotomy
incision and thus introduces the risks of further herniation as well as
potential surgical site infection and subsequent mesh contamination.
The use of laparoscopy in parastomal hernia repair has gained acceptance
as a means of minimizing both the incision size and the potential for
surgical site contamination while still adequately exposing the hernia
defect for suf fi cient mesh overlap.
509
45. Parastomal Hernia Repair: Latest Updates
Laparoscopic Repair
With the popularization of laparoscopic parastomal hernia repair, two
techniques adapted from open intraperitoneal repairs are predominantly
used. The fi rst technique incorporates a procedure described by
Sugarbaker et al. in 1985 [
15, 16 ] . In this technique, the bowel is tunneled
super fi cially and laterally above the mesh, thereby creating a fl ap valve
to prevent further herniation. In the original description, the mesh was
sutured to the fascial edges as an inlay, but today, this procedure is
performed similarly to a ventral hernia repair where the mesh overlaps
the fascial edges by several centimeters.
The keyhole technique is another method used to repair parastomal
hernias [
17– 19 ] . The mesh has a “keyhole” shape or a slit cut into it
allowing the mesh to be wrapped completely around the ostomy with
the edges of the mesh then sutured to the abdominal wall. Although
the concept of this technique is to reinforce the ostomy while covering
the hernia defect, the recurrence rates can be unacceptably high.
Therefore, we have directed our laparoscopic parastomal hernia
repair practice to performing a modi fi ed Sugarbaker technique as
described below.
Laparoscopic Technique
The patient is placed in a supine position, and general anesthesia is
induced with both arms tucked at the sides. All patients are given a fi rst
generation cephalosporin (or appropriate substitute in the case of an
allergy) within 1 h of incision. The abdomen, including the ostomy, is
prepped and draped. A sterile Foley catheter is then inserted into the
ostomy, and the balloon fi lled to assist with identi fi cation of the correct
intestinal loop when lysing adhesions (Fig. 45.1 ). We use a Ioban drape
(3M Company, St. Paul, MN, USA) to cover the abdomen and stoma as
well as to mark the abdomen later when measuring for mesh size.
The peritoneal cavity is accessed using a Veress needle inserted in
the left subcostal margin in the midclavicular line. Once adequate
pneumoperitoneum (15 mmHg of carbon dioxide) is achieved, a 5-mm
OPTIVIEW port is placed superolaterally on the side contralateral to
the ostomy. Two additional 5-mm trocars are placed on this contralateral
side: one laterally on the level of the ostomy and the other inferolaterally
to the ostomy (Fig. 45.2 ). Adhesiolysis is then performed using sharp