Laparoscopic repair of parastomal and incisional hernias with a modified Sugarbaker technique
A 79-year-old woman, who had undergone an abdominoperineal resection for an adenocarcinoma (pT3N0M0, stage II) of the rectum 9 years ago, visited the emergency room with severe abdominal pain and vomiting. She was later diagnosed with a large parastomal and incisional hernias (). She first noticed the parastomal hernia seven years ago. In the past, she sometimes had difficulty with fitting stoma appliances and complained of discomfort due to the severe parastomal hernia. But, she was treated conservatively.\nOn preoperative abdominopelvic computed tomography (CT), a large parastomal hernia with concomitant incisional hernia was observed with a loss of fascia around her ostomy. Herniation of small bowel and greater omentum was observed ().\nAlthough the patient experienced some improvement of symptoms with conservative management early in her hospital stay, the authors determined that a laparoscopic surgery for correction of the parastomal hernia would be necessary for long-term management.\nIntravenous prophylactic antibiotics were given during induction of anesthesia, and the patient was operated under general anesthesia with endotracheal intubation. The patient was positioned supine with both arms alongside her body. The stoma was covered with a gauze and the stoma site was covered with a clean Ioban drape (3M, St. Paul, MN, USA).\nPositioning of the surgeons, trocars and video equipment is shown is given in . Both surgeon and assistant stood on the side of the patient opposite to the stoma site. The first 12 mm balloon trocar intended for the camera was created with an open Hasson technique at the side opposite to the stoma, and a pneumoperitoneum was created with 12 mmHg of intraoperative abdominal pressure. Afterwards, a 30° angled, 10 mm scope was introduced. Next, a second 5 mm trocar was inserted subcostally. Finally, a third 12 mm trocar was placed just above the superior iliac crest ().\nAfter complete lysis of adhesion with sharp dissection of the anterior abdominal wall, we measured the hernia defect and inspected concomitant incisional hernia (). The parastomal hernia sac size was measured to be 7 cm × 5 cm and the concomitant incisional hernia sac size was 6 cm × 5 cm. The extent of the parastomal and incisional hernia defect were marked on the abdomen. A size of mesh was fit according to these marking such that it would be large enough to cover all hernia defects by at least 5 cm in all directions.\nBefore mesh application, the midline incisional hernia was closed with 1-0 Vicryl sutures using the Endo close Trocar Site Closure Device (Covidien, Mansfield, MA, USA) through separate small skin incisions (). We used a 25 cm × 20 cm sized PARIETENE Composite mesh (Covidien) which was used as the original without cutting.\nOrientation marks were made on the mesh and on the abdominal wall to allow for proper intraperitoneal orientation of the mesh. The first sutures were placed at the orientation marks before the mesh was inserted into the abdomen. The mesh was subsequently oriented using the orientation marks and the sutures were extracted through separate small skin incisions at the orientation marks with an Endo close Trocar Site Closure Device. The sutures were tied down to the anterior abdominal fascia, thus creating transabdominal fixation sutures.\nWe placed a transfascial fixation suture laterally in the mesh just above and just underneath the lateralized bowel () and more sutures were placed all around the mesh at its margins. Further fixation was performed with a mechanical fixation device-Autosuture endoscopic tacker (Endo Universal 65° devices, 4.8 mm stapler)-at the margin of the mesh with an interval of about 1 to 2 cm ().\nTotal operating time was 340 minutes and there were no complications during the procedure (). At postoperative day (POD) #1, the patient started tolerating sips of water, and at POD #3, a soft diet was started. Following a brief ileus, the patient was discharged one week after surgery with no other complications. Now, 6 months after surgery, the patient has shown no evidence of recurrence ().