Parastomal and Lateral Defects

Abstract

Parastomal hernia is an intention hernia per se. It is supposed to permit a benign functionality for one dislodged bowel. The surgeon must consider all details to perform the procedure; it should be strategically planned and well completed (Sugarbaker, Surg Gynecol Obstet 169(1):75–77, 1989). Many hidden predisposing complication factors can be presented at the moment of a colostomy (Mylonakis et al., Colorectal Dis 3(5):334–337, 2001). This scenario is challenging when a parastomal hernia develops. The same analogy can be made for lateral defects that occur through drain incisions, closed stoma locations, surgical incisions, or others.

The incidence of major stoma complications could be considered as 46.4%; when minor problems are included that goes up to 56% (Nastro et al., Br J Surg 97(12):1885–1889, 2010). Hernias are likely to happen in 50% of the stomas, even ileostomy or colostomy (Fazekas et al., Ann R Coll Surg Engl 1–6, 2016). Despite the development of groups of clinical nurse stoma specialists, little can be done over parastomal hernias; of those, 10–15% will suffer occlusion, subocclusion, pain, or ischemia. This could be from the herniated tissue or the stoma bowel with various levels of consequences. Surgical options for correcting a parastomal hernia are local primary suturing repair, and relocation with or without mesh or muscle grafts, but the results are limited and poorly efficient with recurrences ranging from 46% to 100% (Israelsson, Surg Clin North Am 88(1):113–125, 2008; Allen-Mersh and Thomson, Br J Surg 75(5):416–418, 1988; Rubin et al., Arch Surg 129(4):413–418, 1994; Hansson et al., Ann Surg 255(4):685–695, 2012). The open suturing repair, with repositioning the ostomy must be abandoned (Hansson et al., Ann Surg 255(4):685–695, 2012). The use of mesh in parastomal hernia repair significantly reduces recurrence rates and is safe with a low overall rate of mesh infection (Geisler et al., Dis Colon Rectum 46(8):1118–1123, 2003). PTFEe mesh used to be the only option for these patients, but infection against the mesh compromises the whole surgery, with the occasional necessity to remove the mesh. In laparoscopic repair, the Sugarbaker technique is superior to the keyhole technique and shows fewer recurrences (Sugarbaker, Ann Surg 201(3):344–346, 1985). Lateral defects are not under those kinds of influence, but because of complexity of large flat muscles, they can have a unique behavior.

We must consider that most services dealing with ostomies are not familiar with hernia repair or even think of robotic use for this abdominal wall reconstruction. These patients have many comorbidities themselves with higher risks for multiple surgeries. The minimal robotic-assisted invasive surgery must be considered in these difficult cases. Mechanical arms can help the surgeon achieve a well-established dissection around the ostomy with the necessary torque to a good practice. It permits cleaning and returning to the cavity all protruded tissue exposing the abdominal wall anatomy details in the deep, noncontaminated field and because of defect recognition allows stitching the anterior aponeurosis, above the muscular layer and proceeding with the Sugarbaker technique in a better way, after defect closure. Some defects between muscles could be repaired by robot suturing superficial aponeurosis from the inside and positioning a preperitoneal mesh.