Laparoscopic Repair of Parastomal Hernias with a Modified - Belsurg

Acta chir belg, 2007, 107, 476-480
Laparoscopic Repair of Parastomal Hernias with a Modified Sugarbaker
Technique
F. Muysoms
Department of Surgery, AZ Maria Middelares, Gent, Belgium.
Key words. Laparoscopy ; parastomal hernia ; abdominal wall hernia ; mesh ; hernioplasty.
Abstract. Background : With the increasing experience in laparoscopic ventral and incisonal hernia repair this minimal
invasive technique has also been used to repair parastomal hernias. Different types of laparoscopic repair have been
described.
Methods : Laparoscopic repairs can mainly be divided in two groups : “keyhole-techniques” and “Sugarbaker techniques”.
We reviewed the literature and described our current technique, using a “modified Sugarbaker technique” in
detail.
Results : We have used the technique in five patients with good early results, no early recurrences and good functional
outcome.
Conclusions : Laparoscopic repair of parastomal hernias is a safe and feasible technique. In our experience, laparoscopic
parastomal hernia repair with “keyhole techniques” had a disappointing high recurrence rate. Therefore we
changed to a “modified Sugarbaker technique” with promising early results.
Introduction
A parastomal hernia is a frequent pathology in patients
with a colostomy or ileostomy (1). Recently it has been
shown that the development of parastomal hernias could
be prevented by placement of a lightweight mesh in a
sublay position at the time of stoma creation (2). A
parastomal hernia is often well tolerated and a repair is
only needed if symptoms like obstruction, incarceration
or difficulty of appliance (colostomy pouch) application.
Many different techniques for repair of parastomal hernias
have been proposed (1).
Open techniques can be divided into : local tissue
repair, repair by stoma relocation and repair with mesh.
Local tissue repair and stoma relocation have a high rate
of recurrence. Moreover stoma relocation caries the risk
of incisional hernia at the old stoma site. In an attempt
to lower the recurrence rates several types of mesh
repairs have been proposed. The position of the mesh
varies from intraperitoneal to preperitoneal or fascial
onlay.
A laparoscopic approach has been proposed to combine
the benefits of minimally invasive surgery with the
use of mesh. Also in the laparoscopic era, different techniques
have been proposed.
Laparoscopic repairs can mainly be divided in two
groups : “keyhole-techniques” and “Sugarbaker techniques”.
Several different types of “keyhole” repairs
have been described (3-7). They all have in common that
the parastomal hernia is repaired with an intraperitoneal
mesh with a central hole or slit in the mesh to allow the
colon or the ileum to pass through the mesh to go to the
stoma site. In so-called “Sugarbaker” or “modified
Sugarbaker” techniques a single uncut piece of mesh is
placed as an intraperitoneal onlay patch. In this paper we
will describe in detail our current technique for repair of
parastomal hernias and give our arguments to prefer a
“modified Sugarbaker” technique over a “keyhole” technique.
“Modified Sugarbaker” technique for laparoscopic
parastomal hernia repair
Sugarbaker described in 1980 an open technique for
repair of parastomal hernias using an intraperitoneallyplaced
polypropelene mesh as an inlay mesh repair (8).
No hole was made in the mesh but the bowel going to
the stoma was lateralized and covered by the mesh. He
reported excellent results in seven patients with no
recurrences at 4 years of follow-up (9).
STELZNER et al. reported a “modified Sugarbaker technique”
in 20 patients. By laparotomy an intraperitoneal
ePTFE mesh, with overlap of the hernia defect of at least
5 cm in all directions was placed (10). With a mean follow
up of 3.5 years, they saw three asymptomatic recurrences
(15%). Several papers have described laparoscopic
adaptations of this successful open Sugarbaker
technique (11-14).

Laparoscopic Parastomal Hernia Repair 477
We would like to define the “Laparoscopic Modified
Sugarbaker technique for parastomal hernia” as : a
repair by laparoscopic technique of a parastomal hernia
by placement of an intact intraperitoneal mesh overlapping
the hernia defect and with lateralisation of the
bowel going to the stoma.
Indications for repair are usually : obstruction, incarceration
and difficulties in applying the stoma appliance
material. It is common practice not to operate on oligoor
asymptomatic patients. Care should be taken not to
broaden the indications for repair of these hernias just
because there is a new minimally invasive technique that
we want to adopt. Not before we have long-term followup
data with low recurrence rates and low complication
rates, might we justify considering to operate on less
symptomatic patients.
Preoperatively some laxatives are given. A proper
bowel preparation could be considered but is not given
in our practice. One single dose of cefazoline is given
during induction of anesthesia. Patients are operated
under general anesthesia with tracheal intubation.
Special attention should be given to patients operated for
incarceration and obstruction to avoid aspiration of
stomach content resulting in pneumonitis by inhalation.
The patient is in the supine position with both arms
alongside the body. The arms should be tucked underneath
the sides of the patients to allow access to the lateral
border of the abdomen where the trocars will be
placed. After desinfection, the operative field is draped.
Again we emphasize the importance of keeping the
operative field broad enough to expose bilaterally the
lateral sides of the abdomen. We cover the stoma with a
gauze and cover the stoma site and the whole operative
field with a plastic drape. Doing this the stoma itself is
during the operation never in contact with the operative
field. Therefore we think the risk of contamination of the
mesh should not be higher than for other laparoscopic
incisional hernia repairs not involving a stoma.
Positioning of surgeons, trocars and video equipment
for a left sided colostomy is given in Fig. 1. Usually a
pneumoperitoneum is created with a Verres needle subcostally
at the anterior axillary line. We use an intraoperative
abdominal pressure of 12 mmHg. When this
pressure has been reached a trocar of 10 mm is inserted
on the same anterior axillary line halfway between the
costal margin and the superior iliac crest. A 30° angeled
scope of 10 mm is introduced. The position of the Verres
needle is checked and lesions to the bowel or the liver by
the puncture are excluded. A second trocar of 10 mm is
inserted subcostally. This will be the site of the scope
during the operation. Finally a third trocar of 5 mm is
placed just above the superior iliac crest. If needed the
region where this trocar is to be inserted is released of
adhesions. If many intraperitoneal adhesions are suspected
an open laparoscopy can be used to create the
Fig. 1
Positioning of trocars, surgeons and equipment for laparoscopic
repair of a parastomal hernia of a left sided colostomy.
pneumoperitoneum as an alternative for the Verres needle
technique.
Complete adhesiolysis of the anterior abdominal wall
is performed, including release of the round ligament of
the liver if this is necessary. Care is taken to avoid accidental
enterotomy. Indeed adhesiolysis can sometimes
be difficult in these patients (15). It is a potentially dangerous
step of the operation, certainly if a bowel lesion
is missed and only recognised postoperatively. Delayed
bowel lesions can result in intraabdominal sepsis and
multiorgan failure. Therefore it is recommended to perform
the adhesiolysis with a sharp dissection, only cutting
under good visibility and with certainty about the
structures being cut. We advise to use energy sources
like coagulation or electronic scissors only scarcely. We
always look for the avascular plane between the adhesions
and the abdominal wall. This avascular plane is
usually present and can be recognised by moderate traction
on the adherent structures. In cases of recurrent
hernias after previous mesh repair the avascular plane
might not be present and adhesiolysis in these cases can
be very difficult or even impossible.
The content of the hernial sac is reduced after identifying
the colon going to the colostomy and its mesocolon.
The peritoneal sac is left in place. To be able to
achieve adequate lateralisation of the colon, we recommend
freeing all adhesions of the colon and its mesocolon
from the margins of the hernia defect. The colon
is pulled intraabdominally, thus reducing a prolaps if
present. The colon is then pulled to the lateral side of the
hernia defect. We fix the colon with some resorbable
sutures between the serosa and the peritoneum lateral of
the hernia defect. Thus we close the opening lateral of
the colon.

478 F. Muysoms
Fig. 2
Intraoperative view showing the mesh used for a modified
Sugarbaker repair of a parastomal hernia.
We measure the hernia defect and check all incisions
on the anterior abdominal wall for concomitant incisional
hernias on these incisions. The hernia defect is drawn
on to the abdomen as well as the concomitant hernias if
present. A size of mesh is drawn outside these drawings
so it will be large enough to cover all hernia defects by
at least 5 cm in all directions (Fig. 2). If a concomitant
incisional hernia is present we repair it with one large
mesh covering both hernia defects.
We recommend to use a mesh designed for intraperitoneal
placement. Some authors have used regular
polypropylene mesh intraperitoneally to repair parastomal
hernias (12). Most authors think this harbours the
risk for extensive adhesions, bowel fistula and mesh
infection. We use an ePTFE mesh (Dualmesh Plus with
Holes ‚, WL Gore, Flagstaff, Arizona, USA) in our practice.
When the mesh has been cut to the appropriate size
and form, orientation marks are made on the mesh and
on the abdominal wall to allow orientation of the mesh
once it has been placed intraperitoneally. At the orientation
marks the first sutures are placed before the mesh is
inserted into the abdomen. When introducing the mesh,
contact with the skin should be avoided. Therefore the
meshes of moderate size are introduced trough a trocar.
Larger meshes that are too big to introduce through a
trocar are rolled inside the sterile plastic covering of the
mesh and are introduced after removal of the trocar.
Inside the abdomen the mesh is removed from its plastic
covering, which is than removed from the abdomen.
The mesh is orientated using the orientation marks and
the sutures are extracted with a “suture passer” technique
through separate small skin incisions at the orientation
marks. The sutures are tied down to the anterior
abdominal fascia, thus creating transabdominal fixation
Fig. 3
Intraoperative view of a laparoscopic parastomal hernia repair.
The colon has been lateralised and the mesh is fixed with a
transfascial suture below and above the colon.
Fig. 4
Fixation of the mesh in a laparoscopic parastomal hernia repair
with a modified Sugarbaker technique. We use a combination
of transfascial fixation sutures and spiral tackers in a double
crown configuration.
sutures. We place a transfascial fixation suture laterally
in the mesh just above and just underneath the lateralised
bowel (Fig. 3). Care is taken not to injure the
bowel. Further sutures are placed all around the mesh at
5 cm intervals at the margin of the mesh. Further fixation
is done with a mechanical fixation device at the
margin of the mesh with an interval of one to two cm
between the fixations. We use spiral tackers (Protack®,
Autosuture, Tyco Health Care Group, Norwalk,
Connecticut, USA) as a fixation device. Then a second
row of staplers is placed at the margin of the hernia

Laparoscopic Parastomal Hernia Repair 479
defect like for a “double crown” fixation. With some
additional staplers we connect these two rows of staplers
at each side of the colon. Again care is taken not to put
staplers into the colon or the mesocolon. Our method of
mesh fixation is explained graphically in Fig. 4.
Results
After having seen a live surgery session where Karl
Leblanc performed a laparoscopic modified Sugarbaker
technique to treat a parastomal hernia we adopted this
technique since November 2005 in all patients presenting
with an indication for repair.
We have operated five consecutive patients with a
symptomatic parastomal hernia. All patients had a left
sided colostomy. Two for adenocarcinoma of the rectum
and three for benign rectal disease leading to a permanent
colostomy. For four patients this was the first time
their parastomal hernia was repaired. One patient had
two previous repairs, the last one including a mesh
repair in the retromuscular position. In four patients a
concomitant incisional hernia, either on the midline or at
an old ileostomy site, was repaired. Indications were
incarceration in one and recurrent obstructions in four.
All patients were treated with one intact ePTFE mesh
covering the parastomal hernia, the lateralised colon and
the concomitant incisional hernia, if present. There were
no intraoperative or postoperative complications. Till
today, no recurrence has been observed, although follow-up
is rather short. No problems with stenosis or
obstructions of the colostomy have been encountered
and colonic irrigation is either as good or better than preoperatively.
We plan to do a prospective multicenter follow-up
study of laparoscopic modified Sugarbaker repair to
repair parastomal hernias to obtain long-term results of
this technique. We will focus on recurrences and functional
outcome.
Discussion
Some reports with keyhole techniques have disappointing
results with high recurrence rates. Safadi reported a
recurrence rate of 56% (5/9 patients) within 6 months of
the operation (7). They recommended changes in the
technique of laparoscopic parastomal hernia repair to
achieve better results.
Initial results with laparoscopic parastomal hernia
repair using a “Keyhole technique” in our experience
were disappointing. Analysis of the recurrences showed
that the weak point of the repair was the hole in the
mesh. It is indeed difficult to estimate the appropriate
size for the hole in the mesh, that optimally accommodates
the colon going to the skin. From experience with
laparoscopic incisional hernia repair we know that the
amount of overlap of the mesh beyond the hernia defect
is an important determinant for the risk of hernia recurrence.
In a “Keyhole technique” the amount of overlap
at the hole is zero. Therefore this will always be a weak
point for developing recurrences. Moreover we know
that an implanted mesh shows a variable degree of
shrinkage. Shrinkage of a mesh with a central hole will
result in enlargement of this hole. These disappointing
results are similar to some results in the literature with
“Keyhole techniques”. Tessier analysed the literature on
laparoscopic parastomal hernia repair and compared the
“Sugarbaker” with the “Keyhole techniques” (16). He
concluded that the “Sugarbaker technique” is superior to
the “Keyhole technique” by offering decreased operating
time, lower morbidity, shorter length of stay and less
recurrence rate. LEBLANC et al., in their most recent
paper on laparoscopic parastomal hernia repair, feel that
the single patch technique as an onlay repair is the better
alternative compared to the keyhole techniques (14).
We currently prefer the “modified Sugarbaker technique”
to repair parastomal hernias laparoscopically.
Not only are we convinced that the recurrence rates will
be lower, but also that this technique is definitely much
easier to perform. It is a laparoscopic adaptation of the
open technique performed by Stelzner, that has proven
its efficacy,with good long term results.
Conclusion
Laparoscopic repair of parastomal hernias is a safe and
feasible technique. In our experience laparoscopic
parastomal hernia repair with “keyhole techniques” had
a disappointing high recurrence rate. Therefore we
changed to a “laparoscopic Sugarbaker technique” with
promising early results.
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480 F. Muysoms
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Abstract P-26, 3 rd International Hernia Congress, Boston.
Dr. Filip Muysoms
AZ Maria Middelares
Kortrijksesteenweg 1026
B-9000 Gent, Belgium
Tel. : 003292607181
Fax : 003292607175
E-mail : filip.muysoms@azmmsj.be