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Official Journal of the American Society of Abdominal Surgeons, Inc.
This article originally appeared in the Winter 2013 / Spring 2014 issue of the Journal.
Paraostomy Hernias: Prosthetic Mesh Repair
Paul H. Sugarbaker, M.D., F.A.C.S., F.R.C.S.
Address for correspondence:
An ostomy is an artificial opening through the abdominal wall for the intestine or ureter in order to discharge intest inal co nt en ts or ur ine. For pat ient s w i th osto m ies, a hernia alongside the viscus that penetr ates the abdominal w a l l is not unusual. Her n ia s that are a s s o ciate d w it h colostomi es, ileostomies, jejunostomies or uros tomies would all be classified as paraostomy hernias.
Patients w ho must u se an ostomy usually to lerate this change in lifestyle well if their quality of life is not impaired. If lea kage of the ostomy with its app liance repe atedly occurs, there is a marked decrease in the quality of life for t h e patient . If a h er n ia is prese nt coughin g , sn eezing , exercise and other act ivit ies that cause any in crease in intraabdominal pressure will of ten dislodge the ostomy appliance. The unnatural protrusion of the abdominal wall is c osmet ic a l l y unacc ept a ble and calls at te n ti on t o t h e presence of th e ostomy. To preserve an optimal quality of life and provide the best possible rehabilitation after surg ic al procedures, it i s imp erative that a reliabl e met hod of repair be used when symptomatic hernia occurs.
MECHANISM OF PARAOSTOMY HERNIA FORMATION
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A paraostomy hernia occurs inpatients who have inadequate wound healing b etween the ostomy tunnel an d the viscus that extends through the abdominal wall. Any condition that decreases wound healing in the early postoperative period will in crease the incidence of paraostomy hernia. Poor nutrition, progressive cancer, obesity, and poor surgical technique that interfere with adherence of bowel wall and abdominal wall are prominent causative factors. Other conditions that would tend to separate these tissues and also lead to an increased incidence of paraos to my herni as include coughing, sneezing , and ascites. The improper location of anostomy through a tendinous portion of the abdominal wall rather than throug h a muscular area will also increase the incidence of paraosto my hernia format ion. ANATOMY AND NOMENCLATURE OF AN INTACT OSTOMY A functional osto my with a secure appliance affords the patient a reasonable quality of life and minimal dysfunction. The structure of the ostomy and its component parts are illustrated in Figure 1.
The portion of the intestine that is to cross the abdominal wall must be brought through the ostomy tunnel along with its intact blood supply. The layers of the abdominal wall that contact the segment of intestine within the tunnel are peritoneum, muscle and fascia, subcutaneous tissue and skin. The ostomy bed is formed by everting full thickness the distal 2 to 3 cm of bowel on itself and securing the mucosal end of the bowel to the skin exit site as a mucosal bud.
INCIDENCE OF PARAOSTOMY HERNIA
Parastomal hernia is the most frequent late complication of an ostomy and is estimated to occur in 10 to 25% of the patients.1-4 The incidence of paraostomy hernia approaches 30% f ollowing abdominoperineal resection.5,6 Following more extensive dissections, such as pelvic exenteration, the incidence is yet higher. Some authors have suggested that paracolostomy herniati on may be reduced if the colon is brought to the abdominal wall through a retroperitoneal approach.7 Others have found that this reduces the incidence of hernia little or not at all.6, 8 Hernias almost universally occur at the lateral aspect of the ostomy site. A separation between the segment of the intestine and the lateral aspect of the tunnel permits peritonealization of periostomy space so that omentum or small intestine can move into the space. With time, this space expands and a hernia progressively increasing in size is formed. The greater the intraabdominal pressure, the more rapid the progression of the hernia.
REPAIR OF PARAOSTOMY HERNIA
In the past, the incidence of paraostomy hernia recurrence following repair was high. However, success with the technique is limited and recurrence rates of 50% were not unusual. Three different approaches to paraostomy hernia repair have been previously reported. Thorlakson advocated a direct surgical attack on the hernia; the hernia, usually occurring lateral to the stoma site, is opened, the sac is dissected away, colon is secured to the abdominal side wall and fresh fascial edges are tightened up around the intestine. 9 Goligher suggested an operation to relocate the colonic stoma with direct repair of the abdominal wall defect.8 In most paraostomy hernias, direct reapproximation of fascia to close the defect is not possible. Three manuscripts (Rosin and Bonardi, Abdu, and Garajobst and Sullivan) advocated the use of Marlex mesh in an onlay position within a contaminated operative field surrounding a stoma.10-12 This approach may cause serious infectious complications because of bacterial contamination of the mesh by the stoma itself which must be within the operative field. These authors reported only minor problems with sepsis in the patients studied. Nevertheless, the use of foreign material in a contaminated operative field should be avoided if possible.
SURGICAL PROCEDURES FOR INTRAPERITONEAL APPROACH TO PARAOSTOMY HERNIA REPAIR
FIGURE 2 (TOP)
Large paraostomy hernia at the site of an end sigmoid colostomy in a patient who had undergone pelvic exenterative surgery for recurrent cervical cancer. Prior attempts at repair using the Thorlaksen approach had been unsuccessful.
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Prosthetic mesh can be used in a sublay position for repair of the fascial defect without the problems that bacterial contamination of the operative field presents.13 The mucosal bud is not disturbed, and this facilitates rapid return to normal intestinal function. The hernia defect is closed with prosthetic material and approximately 10 cm of bowel exiting from the ostomy tunnel is also covered by mesh. This repair has been referred to as the "Sugarbaker repair" or "Pocket repair" of a paraostomy hernia.
The intestine is prepared as for a colonic operation using a through mechanical preparation. A short course of perioperative systemic antibiotics is begun before surgery. To facilitate location of the bowel proximal to the ostomy intraoperatively, a rubber catheter or endoscope is passed approximately 20 cm into the colon. The colonic stoma is walled off from the operative field using an adhesive plastic drape.
FIGURE 2 (BOTTOM)
The same hernia following a peritoneal approach for the Sugarbaker repair. The small bulge in the skin lateral to the stoma is colon above the mesh. The colon enters the abdomen laterally through the open end of the mesh pocket.
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In a large paraostomy hernia, bowel and omentum are usually found within the hernia sac. This is the anatomic situation encountered in the patient shown in Figure 2 and in a recurrent paraostomy hernia.
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A peritoneal approach is taken to expose the paraostomy hernia. This requires a generous opening of the old midline or paramedian incision.
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Prosthetic mesh is used to close the hernia defect. The bowel loop exiting at the ostomy site is covered laterally by the mesh. It enters the abdominal space by exiting from the open end of the mesh pocket.
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The abdomen is closed after the hernia is repaired.
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Figure 2 top and bottom shows a large paracolostomy hernia before and after this type of repair. Figure 3 shows the anatomic situation found in the patient shown in Figure 2 with small intestine alongside the exiting colon. Fascial edges were widely separated and the peritoneum and skin were greatly stretched out.
In the peritoneal approach using laparotomy, this procedure differs from other repairs done for paraostomy hernias described so far in that the old midline or paramedian abdominal incision is reopened. After the old incision has been widely divided, Adair clamps or self-retaining retractors are used to place upward traction on the fascial edge of the left side of the abdominal incision. As adhesions are dissected away, the contents of the hernial sac are delivered into the abdominal cavity (Figure 4). The portion of the bowel exiting through the colonic stoma is easily located because it was earlier intubated with a large catheter or endoscope. It is important to identify clearly the fascial ring at the perimeter of the hernia. It is not mandatory to dissect the parietal peritoneum out of the hernia sac, but this is usually accomplished without difficulty if the exposure is adequate. A horseshoe-shaped piece of prosthetic mesh is cut so it will snugly fill the fascial defect. The size of the hernia defect is reduced as much as possible without causing excessive tension that could cause sutures to pull through. This prevents a bulge that may occur as a result of loose mesh. Sutures are individually placed at approximately 1 cm intervals around the fascial ring except directly laterally where the bowel will enter the abdominal cavity from the subcutaneous tissue. Of course, the internal exit site of the bowel from above the mesh must not be too tight. Also, a flap of mesh 2-3 cm beyond the sutures will protect against herniation beneath the mesh. Sutures are secured to the mesh so that all sutures are under equal stress, and it is therefore, unlikely that individual sutures will pull through. The bowel is led out over the mesh to the lateral abdominal wall. Below the exit of bowel from above the mesh, it is secured with non-absorbable sutures (Figure 5). The abdominal incision is closed in a routine manner (Figure 6).
DISCUSSION REGARDING THE CHOICE OF A TYPE OF PARAOSTOMY HERNIA REPAIR
In a small paraostomy hernia in which a small fascial defect leads to the accumulation of bowel and omentum in a subcutaneous pocket, hernia repair is often accomplished by a direct surgical attack on the problem. In the repair described by Thorlakson, the hernia is opened, the fascial defect is closed with non-absorbable suture material.9 Although this simple surgical procedure meets with success in some patients, long term success is not usually achieved. Even with the most meticulous technique, repair of these large hernias usually fails and recurrent hernias can be seen sometimes just weeks after repair.
Patients with recurrent paraostomy hernias tend to have a larger fascial defect that can only be closed under great tension. If the ostomy is moved to another site as suggested by Goligher, the hernia at the original ostomy site may often recur.8 Also, no reason for a new paraostomy hernia not to occur at the new ostomy site exists. Finding an optimal site for the new ostomy is often impossible.
My own experience with an open prosthetic mesh repair of paraostomy hernias has been excellent.14 In long-term follow-up the prosthetic mesh has not become infected. The fibrous ingrowth that surrounds the mesh in time permanently prevents recurrence of a hernia at the ostomy site. Other problems such as prolapse and stenosis have not occurred. In the urostomy patient no urine stasis within the conduit or increase in the frequency of urinary tract infections occurred. Our unusually low incidence of recurrence may be related to the elimination of radial forces of the abdominal wall directed at the interface of bowel and ostomy tunnel. In this repair, an increase in intraabdominal pressure is exerted directly onto the mesh. The oblique course of the bowel above the prosthetic mesh prevents intraabdominal forces from separating the bowel from the lateral portion of the ostomy tunnel. Our favorable results suggest that prosthetic mesh repair is indicated for recurrent enterostomy hernias or enterostomy hernias with a large fascial defect.
Hansson and coworkers performed a systematic review of the surgical techniques that have been reported for parastomal hernia repair.15 Primary outcome of their study was recurrence after at least 1 year follow-up. Secondary outcomes were mortality and postoperative morbidity. Thirty studies were included in the systematic review. A direct approach with suture repair was reported in five retrospective studies of 106 patients. Recurrence rate was 70%, overall morbidity was 22.6% and surgical site infection developed in 11.8%. From this systematic review, recurrence rates are prohibitively high and morbidity large even though the procedure was limited in its extent.
An onlay mesh placed between subcutaneous tissue and anterior rectus sheath occurred in 157 patients in 7 series.15 In most reports a keyhole technique was used. Recurrence rate was 19%, overall morbidity was 12.7% and mesh removal performed because of infection occurred in 3%. Retromuscular mesh repair was always performed by a keyhole technique. Three studies reported a total of 49 patients. Recurrent hernia was seen in 6.9% and a wound infection in 4.8%.
Long-term follow-up is needed to evaluate this approach. A major potential problem with any keyhole-type of mesh repair is late stenosis of the ostomy from shrinkage. As the mesh becomes infiltrated or surrounded by fibrous tissue, shrinkage of the mesh will occur and a reduction in the diameter of the hole in the prosthetic material. The number of patients requiring ostomy revision as a result of stenosis may be large and many years of follow-up required to evaluate this potential adverse outcome.
The open intraperitoneal mesh repair through the prior midline incision is often used for the large and recurrent hernias. The adverse events were usually related to exposure of the hernia defect; difficulties dissecting dense adhesions caused by prior surgery and enterotomies as a result of adhesiolysis were often mentioned as part of the requirement for exposure of the hernia defect and in placement and suture of the mesh.
Two techniques are used to repair parastomal hernias with an intraperitoneally placed prosthesis: the "Sugarbaker" technique and the keyhole technique. In 1980, Sugarbaker described a new technique for parastomal hernia repair.13 Via a laparotomy, the hernia defect is closed with an interposition of prosthetic mesh securely sutured to the fascial edge. The bowel is lateralized passing from the hernia sac between the abdominal wall and the prosthesis into the peritoneal cavity. Six recurrent and one primary parastomal hernia were repaired, and no recurrences were reported after a mean follow-up of 5 years.14
Stelzner and colleagues presented the results of an open Sugarbaker repair in 20 paracolostomy hernias.16 Repair was done using a large e-PTFE prosthesis covering the hernia defect. An important technical improvement of Stelzner and colleagues was their use of a minimal 5 cm overlap beyond the fascial edge of the hernia defect. One intraoperative complication (urinary bladder trauma) and 2 major postoperative complications (bowel obstruction secondary to dense adhesions unrelated to the mesh and a pulmonary embolism) were reported. Three recurrences (15.0%) after a mean follow-up of 42 (range 3-48) months were found. All these recurrences were asymptomatic and treated conservatively.
Hansson summarized in their systematic review 4 studies in which the keyhole technique was used. There were a total of 65 intraperitoneal parastomal hernia repairs.15 Both a single wound infection and a mesh infection were reported (2.2%) Overall morbidity was 22.2%. Follow-up was adequate in 3 of 4 series using the keyhole technique. Recurrent hernia was found in 3 of 32 patients (9.4%). No stenosis of the bowel as it exited through the hole in the mesh was reported.
LAPAROSCOPIC INTRAPERITONEAL MESH REPAIR
The greatest number reports regarding paraostomy hernia reported since the year 2000 use a minimally invasive technique. As summarized in Hansson's systematic review in 6 studies reporting on 110 Sugarbaker repairs, a recurrent hernia was reported in 11.6%. In 7 studies reporting on 160 repairs using the keyhole technique, recurrence was reported in 20.8%. All studies had a minimum follow-up of 12 months. These differences were statistically significant.15
Several studies included patients who had the Sugarbaker repair and other patients operated on at the same institution who had the keyhole technique. For example, Muysoms noted a recurrence of 8 of 11 patients (73%) after the keyhole repair and 2 of 13 patients (15%) after the Sugarbaker repair.17 In all reports where both techniques were used, the recurrence was less with the Sugarbaker technique.
Hannson and coworkers performed a multicenter retrospective study of long term results with a laparoscopic paraostomy hernia repair using the Sugarbaker technique in symptomatic patients. They reported on 61 patients gathered from 5 institutions. The mean follow-up was 26 months. The overall morbidity was 19% and the recurrence rate was 6.6%.18
In order to adopt the Sugarbaker technique to laparoscopy, important modifications of the repair were needed. An overlap of 3 to 5 cm of mesh around the fascial edges of the hernia closed by the mesh is mandatory. This skirt of mesh was also secured to the anterior or lateral abdominal wall (Figure 7).
Sugarbaker mesh technique of paraostomy hernia repair using a minimally invasive technique. A 3-5 cm overlap of mesh beyond the hernia defect is recommended.
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Asif and colleagues modified the laparoscopic Sugarbaker technique to guard against a bulge occurring postoperatively. As much as possible, they closed the fascial defect primarily prior to mesh placement. With this added first step of the repair, the mesh that reinforces the closure does not need to downsize the hernia defect but rather a simple underlayment is secured to the peritoneum and posterior rectus sheath.19 However, the defect may be too large to close prior to application of the mesh. In the laparoscopic technique or the open technique it is important using the central portion of the mesh to downsize the fascial defect as much as possible (avoiding excessive tension) in order to prevent a bulge of mesh at the prior hernia site.
Hansson and colleagues emphasized the possibility of other hernias that may be present along with the paraostomy hernia. The most common additional abdominal defect is at the midline incision immediately adjacent to the ostomy tunnel. If there is a defect or thinning of the old midline abdominal incision this should be reinforced by the medial portion of the mesh in addition to the lateral extension that acts as a flap valve covering the entrance of the bowel back into the abdomen.18
KEYHOLE APPROACH VERSUS SUGARBAKER REPAIR
In the Sugarbaker intraperitoneal repair of a paraostomy hernia, tension (shown by arrows) on the mesh does not occur at the junction of bowel wall and the tunnel entrance. Also, to relieve strong tension the curvilinear shape of the mesh can straighten to compress the bowel and thereby absorb stress. The unattached portion of the mesh at the open end of the pocket allows for dissipation of inter-mittently increased tension without disruption of the mesh attachment to the fascial edge of the hernia and the post- erior rectus sheath.
FIGURE 8 (BOTTOM)
With the keyhole repair, tension (shown by arrows) on the edges of the mesh will be transmitted to the interface of the seromuscular layer of bowel and tunnel entrance. This accounts for the high recurrence rate when this type of mesh configuration is used.
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A controversy regarding laparoscopic repair of paraostomy hernia concerns a choice of surgical approaches. Basically, two alternatives exist, the Sugarbaker repair or the keyhole repair. The anatomical engineering of the Sugarbaker repair is superior to that offered by the keyhole repair and may account for the superior long-term results. With intermittent increases in intraabdominal pressure, tension on the mesh will occur by radial forces from the abdominal wall musculature. The Sugarbaker approach prevents these forces from expanding the space between the seromuscular layer of the bowel and the ostomy tunnel entrance. In contrast, with the keyhole technique radial forces at the periphery of the mesh will be transmitted to the interface of the hole in the mesh and the bowel exiting from the ostomy tunnel. The high incidence of recurrence of the keyhole technique is a result of an imperfect design of the repair (Figure 8 top and bottom).
The hypothesis presented earlier in this manuscript related the causation of a paraostomy hernia to the separation of the ostomy tunnel from the seromuscular layer of the bowel. The separation was observed to be most likely to occur at the lateral aspect of the ostomy tunnel. The placement of a mesh to close and then generously cover the lateral defect is more likely to prevent a recurrent hernia than the keyhole technique. Although the keyhole technique is technically simpler to perform and completely covers the hernia defect, there is a high likelihood of the tunnel entrance to again separate from the seromuscular layer of the enteric segment if not corrected. The mesh that closes the hernia defect and covers the segment of bowel exiting the tunnel results in a low incidence of recurrence. A hole or slit in the mesh to allow the bowel to exit directly into the abdominal space is contraindicated.
Hansson and coworkers analyzed the results of 54 patients repaired by the keyhole technique. They found an unacceptable 37% incidence of recurrent parastomal hernia. Approximately half of these patients with recurrence required a redo surgery. At reoperation on these patients, they observed that the mesh appeared smaller and the central opening wider as a result of continued intraabdominal pressure. The widening of the central keyhole was, in their judgment, responsible for the recurrence. The intraabdominal pressure and radial forces working from the abdominal wall onto the mesh tend to cause this approach to reconstruction to be flawed. They conclude that the Sugarbaker technique is less vulnerable in the case of mesh shrinkage compared with the keyhole technique.20
In the original description by Sugarbaker of the intraperitoneal paraostomy hernia repair, the hernia itself was repaired with an interposition of mesh. Only hernias that had a well developed fascial ring that would accept secure placement of sutures were recommended for this approach. Patients who have large recurrent hernias that had been operated several times often have a very firm ring of scar tissue at the edges of the hernia and were especially good candidates for the interposition placement of mesh. Currently, with the open repair an overlap of mesh approximately 5 cm beyond the edge of the hernia defect is recommended. A fold of the mesh is secured to the fascial ring of the hernia in order to shrink the defect as much as possible. Then the overlap is securely attached to the posterior rectus sheath to give a second line of support to counteract recurrent hernia. Alternatively, a second layer of mesh can be used.
The Sugarbaker repair uses a principle that is seen in normal human anatomy for hernia prevention. For example, the spermatic cord in the male crosses the abdominal wall in the inguinal region by traversing both an internal and external ring. These two exit sites are not in the same plane because the conjoint tendon forces the cord to exit through the external inguinal ring 5-7 cm medial to the internal ring. The flap of mesh extending over the bowel entering the abdominal wall separates the exit sites in a similar manner.
THE OPTIMAL PROSTHETIC MATERIAL
The data is clear regarding the optimal technique to be used to prevent or to repair a paraostomy hernia. The Sugarbaker approach (pocket repair) is preferred. What is not currently apparent is the optimal prosthetic material that should be recommended for open repair or for laparoscopic repair. Financial considerations may also be relevant. For open or for laparoscopic Sugarbaker repair, an expanded polytetrafluorethylene (ePTFE) mesh has been used extensively (Gore dual mesh, WL Gore Inc., Flagstaff, AZ).
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