|Year : 2019 | Volume
| Issue : 2 | Page : 148-153
Laparoscopic repair for parastomal hernia with ongoing barbed suture followed by sandwich-technique: 'Sandwich-plus-technique'
Reiko Wiessner, Thomas Vorwerk, Alexander Gehring
Department of General and Visceral Surgery, Bodden-Kliniken Ribnitz-Damgarten, Ribnitz-Damgarten, Germany
|Date of Submission||23-Nov-2017|
|Date of Acceptance||20-Dec-2017|
|Date of Web Publication||12-Mar-2019|
Dr. Reiko Wiessner
Department of General and Visceral Surgery, Bodden-Kliniken Ribnitz-Damgarten, Sandhufe 2, 18311 Ribnitz-Damgarten
Source of Support: None, Conflict of Interest: None
The incidence of parastomal hernias after a permanent stoma is between 50% and 80% depending on the type of stoma, the definition of the hernia (clinical or radiological), and the length of the follow-up. Surgical therapy is complex and involves several techniques with different recurrence rates. We present three cases where we have closed the hernia gap with continuous, non-resorbable, self-retaining sutures with subsequent use of the sandwich technique ('Sandwich-plus-technique'). There were pronounced parastomal hernias in three female patients (mean age was 72 years and the range was 63–78 years) with permanent colostomata. After laparoscopic adhesiolysis, the closure of the hernia defect was completed with ongoing, barbed non-resorbable 1-0 sutures (polybutester) followed by the sandwich technique. There were no intraoperative complications and currently no clinical or radiological evidence for recurrences of the parastomal hernia. Closure of the hernia gap leads to the additional reconstruction of the lateral abdominal wall, resulting in a larger contact surface for integration of the keyhole mesh and thus prior to implantation of the Sugarbaker mesh. The laparoscopic augmentation of large parastomal hernias using the 'Sandwich-plus-technique' is technically complex but achieves very good results in our case series. Further studies and long-term results should prove that the low recurrence rate of the sandwich technique can be further reduced.
Keywords: Barbed suture, parastomal hernia, sandwich-plus-technique
|How to cite this article:|
Wiessner R, Vorwerk T, Gehring A. Laparoscopic repair for parastomal hernia with ongoing barbed suture followed by sandwich-technique: 'Sandwich-plus-technique'. J Min Access Surg 2019;15:148-53
|How to cite this URL:|
Wiessner R, Vorwerk T, Gehring A. Laparoscopic repair for parastomal hernia with ongoing barbed suture followed by sandwich-technique: 'Sandwich-plus-technique'. J Min Access Surg [serial online] 2019 [cited 2019 Dec 7];15:148-53. Available from: http://www.journalofmas.com/text.asp?2019/15/2/148/228412
| ¤ Introduction|| |
The development of parastomal hernias following permanent stomata is very common. Computed tomography (CT) examinations, for example, show rates of up to 80%. Not all parastomal hernias are symptomatic or significantly affect the quality of life. This, combined with the fact that in some procedures may result in high rates of recurrence and complication, leads to much lower numbers of operations than would be expected. Due to the high incidence of parastomal hernias, prophylactic mesh implantation in primary permanent stoma placement is thus performed in studies.
As with a 'standard' incisional hernia, various methods exist in the management of a parastomal hernia, which generally involves the use of a plastic or biological mesh in open or laparoscopic technique in the respective layers of the abdominal wall. The therapy of symptomatic parastomal hernias in both open and laparoscopic techniques is not a routine procedure and is a challenge, in particular, due to the potential complications and the expected recurrence rate.
In the laparoscopic procedure we prefer, three methods are described in the literature:
- The keyhole technique, where an incised mesh is placed around the stoma 
- The Sugarbaker technique with implantation of a mesh which leads to lateralisation of the stoma 
- The sandwich technique combining both methods.
After Hansson et al. (2009) initially reported a low recurrence rate using the keyhole technique (3), there were then recurrences of up to 40% during the follow up period. Using the conventional technique introduced by Sugarbaker in 1985, the stoma loop is lateralised by >5 cm between the mesh and the abdominal wall. Using this procedure, the rate of recurrence was significantly reduced, although some groups still demonstrated recurrences between 20% and 33.3%., From these unsatisfactory results of the individual procedures, Berger and Bientzle concluded that the combination of both techniques should thus be accompanied by a reduction in recurrence rates. The central hole should not be larger than 1.5 cm, and fixation should be done with both transfascial sutures and spiral tacks. The colon is lateralised in the Sugarbaker technique, with the second larger mesh. Berger and Bientzle achieved a significant reduction of the recurrence rate to 2% after 20 months in 47 patients with acceptable morbidity  using the sandwich technique. The sandwich technique has been used in our clinic since May 2015. All cases are listed in the German hernia register HERNIAMED.
| ¤ Case Reports|| |
The first case presented here is a parastomal hernia Type IV according to the Endohernia Society (EHS) classification  with a gap of about 8 cm × 7 cm and consecutive incisional hernia or missing ventral abdominal wall after multiple surgeries and morbid obesity. Patient history of the now 63-year-old multimorbid female patient revealed the extirpation of a neurofibrosarcoma in the small pelvis without bowel resection followed by radiation in 1976. In February 2005, as a late episode after radiotherapy, a rectal perforation occurred, and hence that a discontinuity resection using the Hartmann's procedure was performed with the installation of a terminal sigmoid stoma. In August 2010, an extensive small bowel resection as well as subtotal colectomy by incarcerated incisional hernia with a terminal ascending stenosis in the right middle abdomen had to be performed. Over the past 12 months, recurrent subileus symptoms have developed, most recently with associated cardiac and renal decompensation, and hence that surgical treatment options were discussed with the patient. A colonoscopy showed a hernia-related stenosis in the area of the parastomal hernia, which could not be overcome colonoscopically. A CT was performed [Figure 1] and could not definitively exclude further stenoses. However, the oral contrast agent could be visualised up to parastomal hernia in dilated intestinal loops. Due to the size of the parastomal hernia, in addition to the sandwich technique, a direct laparoscopic hernia closure in the sense of an intra-peritoneal on lay mesh (IPOM)-plus technique was favoured as augmentation. The additional treatment of the abdominal wall defect should not be performed simultaneously due to the pronounced perioperative risk.
|Figure 1: Computer tomography showing the parastomal hernia and the abdominal wall defect in Case 1|
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Following extensive perioperative management, including a peridural catheter and central venous catheter, invasive blood pressure monitoring, optimal positioning (secure fixation for positioning manoeuvres), primary access to the optic trocar (10 mm) was performed openly in the left upper abdomen. The other trocars (1 mm × 12 mm, 2 mm × 5 mm) were gradually inserted in an optimal position relative to the parastomal hernia. Primarily, in the adhesions described above, extensive, on-demand extended adhesiolysis [Figure 2] was performed. After completely separating the adhesions in the area of the hernia gap with additional deperitonealisation, and after insertion of a 15 CH Blake drainage into the former hernia sack, the closure of the hernia gap was effected directly by means of non-resorbable V-Loc™ suture 1/0 (Medtronic GmbH, Meerbusch, Germany) with a stitch spacing of 1.5 cm to the margin and 1.5 cm from stitch to stitch [Figure 3]. Thereafter, the stabilisation of the lateral abdominal wall was operated by a 20 cm × 20 cm Sofradim Paritex™ composite mesh (Medtronic GmbH, Meerbusch, Germany), cut oval (inner diameter 20 mm) for the keyhole technique and after introduction into the abdominal cavity, by means of transfascial sutures and ReliaTacks ™ (Articulating Reloadable Fixation Device, Medtronic GmbH, Meerbusch, Germany) was fixed in double-crown technique. For the final Sugarbaker procedure, a special Sofradim Polyester Mesh ™ (Medtronic GmbH, Meerbusch, Germany) was implanted for parastomal hernias, which has a coated portion in the area of the lateralised intestinal portion to prevent mesh migration. The fixation of the 20 cm × 15 cm net was also done with four non-resorbable TiCron ™ 0/0 sutures and the ReliaTack ™ system in double-crown technique [Figure 4].
|Figure 2: Hernia gap after extensive adhesiolysis and with insertion of a 15 CH Blake drainage into the former hernia sack|
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|Figure 3: Closure of the hernia gap with non-resorbable V-Loc™ suture 1/0 (Medtronic GmbH, Meerbusch, Germany)|
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|Figure 4: For the Sugarbaker procedure, a special Sofradim Polyester MeshTM (Medtronic GmbH, Meerbusch, Germany) was implanted. This mesh has a coated surface in the area of the lateralised intestinal portion to prevent mesh migration|
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The operating time was 177 min. There was no significant intraoperative bleeding. The post-operative course was prolonged. After removal of the inserted drainage, a haematoma formed in the area of the former hernia sack, which was then drained by sonography. After dislocation of the drainage, it had to be repositioned with sonographic support when a seroma formed. In addition, there was a prolonged urinary tract infection in the face of existing chronic renal insufficiency and hence so that this female patient could only be discharged on the 27th postoperative day. The follow-up is 22 months so far. The patient, after being symptom-free for 11 months, underwent an open operation in another hospital due to renewed ileus symptoms. The ileus was caused by adhesion interenterics; a recurrence of the parastomal hernia was not present. In the case of a known abdominal wall defect, the implantation of a 30 cm × 30 cm mesh took place. So far, there has been no recurrence in the area of parastomal hernia with good patency.
The second case presented here is a 78-year-old female patient, a parastomal hernia EHS Type III available in the left middle abdomen after laparoscopically-assisted abdominoperineal rectal extirpation of a neoadjuvant (short-term treatment with 5 Gy × 5 Gy) pretreated rectal carcinoma (ypT3a, ypN0 (0/15), V0, L1, Pn0, R0, G2, cM0, UICC Stage IIa). The parastomal hernia had developed within 1 year of rectal amputation with a concomitant monstrous perineal hernia. Six months after the parastomal hernia had been treated, the perineal hernia was also treated laparoscopically in a two-mesh technique.
The female patient is free of recurrence and metastases in oncological follow-up. The tumour markers carcinoembryonic antigen and carbohydrate antigen-19-9 are still in the normal range. The preoperative CT scan shows the parastomal hernia with a hernia size of 6 cm as well as the additional perineal hernia. The female patient has arterial hypertension, peripheral arteriosclerosis with angioplasty and five-fold stent implantation in the left iliac artery, hyperlipoproteinaemia, and a previous right humeral fracture as comorbidities. Here too, extensive perioperative management took place. The first trocar was inserted openly into the area of the right costal arch. Intraabdominally, there were no adhesions. After closing the hernia defect with V-Loc ™ suture 1/0 with a stitch spacing of 1.5 cm to the margin as well as from stitch to stitch, a 15 cm × 15 cm Sofradim Paritex™ composite Keyhole-Mesh (Medtronic GmbH, Meerbusch, Germany; inner diameter 20 mm) placed around the colostomy and fixed by four transfacial sutures (TiCron ™ 0/0, Medtronic GmbH, Meerbusch, Germany) to the abdominal wall. Additional fixation was performed using 30 AbsorbaTacks™ (Medtronic GmbH, Meerbusch, Germany) in double-crown technique. This was followed by the implantation of the 20 cm × 15 cm Sofradim Paritex™ composite mesh for lateralisation of the colon. The fixation is also carried out using four transfascial sutures (TiCron ™ 0/0) and 45 AbsorbaTacks™ in double-crown technique. In addition, one drainage was inserted in the only partially resected hernia sac.
The operating time was 102 min. There was no bleeding in this patient as well. The patient was discharged on the 7th postoperative day. The follow-up is 26 months. She is symptom-free and recurrence-free with a high quality of life.
The first contact with the 75-year-old, similarly multi-morbid female patient occurred through the Emergency Department for chronic subileus and recent additional 10 cm stoma prolapses. The colostoma in the left middle abdomen was created conventionally 8 years ago as a discontinuity Hartmann resection. The cause was a spastic tetraparesis and quadriplegia after incomplete paraplegia with rectal and bladder paralysis, and hence that an epicystostomy was also performed. The patient had a chronic pain syndrome with a subcutaneous (morphine) pain pump and additional opioid therapy. In the past few years, most recently in 2011, conventional direct hernioplasty without implantation of mesh material had taken place at another hospital. Conservative therapy relieved the oedematous mucosa in the stoma prolapse within 7 days, and subsequently, the prolapse could be retracted. The preoperative diagnosis showed the recurrence of a parastomal hernia Type III (EHS classification) with a diameter of 6 cm × 7 cm.
Again, the first trocar (10 mm) in the area of the right costal arch in the anterior axillary line was created primarily as an open incision. Extensive adhesion of small intestinal loops to the anterior abdominal wall resulted in complete adhesiolysis of the anterior abdominal wall without enterotomy. After subtotal deperitonealisation of the hernia gap, the occlusion of the hernia defect was performed using V-Loc ™ suture 1/0 with the stitch spacing previously described. Before hernia defect closure and mesh implantation, the insertion of a 15 French Blake drainage was performed in the partially resected hernia sack. Subsequently, a 15 cm × 15 cm Dynamesh-IPOM (Dahlhausen, Germany) was placed around the colostomy as a keyhole mesh (inner diameter 20 mm) and fixed to the abdominal wall by four transfacial sutures (TiCron™ 0/0). In addition, fixation was performed using 30 AbsorbaTacks™ in double-crown technique. The further procedure was carried out as described in Cases 1 and 2 with a 20 cm × 15 cm Sugarbaker mesh.
The operating time was 115 min. Again, there was no bleeding. Postoperatively, the patient initially complained of the severe pain in the area of the surgical site, which was treated with a combination of tapentadol 2 mg × 200 mg, metamizole 4 mg × 1000 mg, pregabalin 2 mg × 75 mg pregabalin oral and dexketoprofen 2 mg × 50 mg intravenous. The female patient was discharged on the 8th postoperative day. The follow-up is currently at 8 months. One of the eight transfascial sutures had to be removed in the chronic fistula.
None of the patients experienced oedema of the stoma mucosa postoperatively or even necrosis due to the additional occlusion of the hernia gap. Only one patient had a hematoma or seroma despite deperitonealisation and drainage insert.
| ¤ Discussion|| |
The occurrence of parastomal hernias is common and unavoidable. Clinically, up to 70% and radiologically, even >80% of all patients show a parastomal hernia within the 1st year after an enterostoma., In addition, factors such as obesity, chronic obstructive pulmonary disease, old age, steroid use and malnutrition play a role in the development of a parastomal hernia. Mesh-based techniques have become established in the therapy of the parastomal hernia, although, as in our Case 3, in this female patient three surgeries were performed in recent years at another hospital without implantation of a mesh. Despite mesh implantation in open or laparoscopic techniques, the recurrence rates of 10%–50% and especially the wound complication rates with the open technique are high. In particular, the wound infection rates are significantly lower when using the different laparoscopic techniques. Thus, the evaluation of the National Surgical Quality Improvement Program of the American College of Surgeons by Halabi et al. shows that the laparoscopic operation of parastomal hernias is associated with a shorter operative time and hospital stay as well as the lower risk of overall morbidity and surgical site infections. At the beginning, we presented the possible laparoscopic techniques. Because of the excellent results of Berger and Bientzle, we decided in our clinic for the sandwich technique. As a disadvantage of the method, and in addition to the costs (2 IPOM-Meshes) incurred, we see the introduction of twice as much foreign material compared to the keyhole or Sugarbaker technique. The first keyhole mesh implanted by Berger et al. to bridge the hernia defect and thus only stabilise the lateral abdominal wall, we considered whether this first mesh would not be dispensable by a direct closure of the hernia gap with a non-resorbable suture. A similar strategy was pursued by Rajapandian et al. with direct hernia defect closure by a non-resorbable Prolene 1/0 suture with subsequent implantation of a keyhole mesh. The authors deliberately chose the keyhole technique of supplying an ileal conduit, as they viewed the Sugarbaker technique as problematic when the ureters entered the ileal conduit. In October 2017, we successfully operated on a patient with parastomal hernia in the ileal conduit after cystectomy 2010 with our 'sandwich plus technique.' The implantation site of the ureters into the conduit did not represent a hindrance to lateralisation in Sugarbaker technique. Due to the lack of follow-up of at least half a year, we did not present this latest patient in our case series.
However, our three cases were colostomata, which can be treated relatively easily with the laparoscopic Sugarbaker technique. Since all three patients had multiple recurrences (Case 3), a complete abdominal wall defect (Case 1), or a monstrous perineal hernia (Case 2) in addition to the large parastomal hernias of EHS classifications III and IV, we chose the sandwich technique after direct laparoscopic hernia defect closure with a self-sustaining non-absorbable suture and called this technique 'sandwich-plus technique.' The aim was to use our technique to bring about additional stabilisation of the lateral abdominal wall next to the keyhole mesh and to prevent recurrence as often as possible in all cases. We have succeeded in all cases in the follow-up we have carried out so far. Whether the implantation of the keyhole mesh after direct hernia closure before the Sugarbaker procedure can be dispensed with ('Sugarbaker-plus-technique'), should be decided individually on the basis of the existing recurrence risk of each patient.
| ¤ Conclusion|| |
The laparoscopic augmentation of large parastomal hernias in 'Sandwich-plus-Technique' is technically complex, but in our cases achieved good results without previously occurring complications such as stenosis or fistula formation and thus provides a possible useful extension of the sandwich technique for patients after multiple recurrences or a pronounced abdominal wall weakness.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]