Surg Endosc DOI 10.1007/s00464-015-4370-z
and Other Interventional Techniques
Laparoscopic parastomal hernia repair: No different than a laparoscopic ventral hernia repair? Salomon Levy1 • Margaret A. Plymale1 • Michael T. Miller2 • Daniel L. Davenport1 John Scott Roth1
•
Received: 14 January 2015 / Accepted: 22 June 2015 Ó Springer Science+Business Media New York 2015
Abstract Background Parastomal hernia (PH) is a common complication when a stoma is used. The high incidence (35–50 %) and patient longevity have created a situation where patients are being referred for consideration of repair with more frequency. Due to the presence of an ostomy and the increased bacterial contamination of the area, the insertion of a prosthetic material is concerning for complications. Laparoscopic repair of parastomal hernias utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes. The purpose of this study is to demonstrate that laparoscopic PH repair has outcomes similar to laparoscopic ventral hernia (LVH) repair without the presence of a stoma. Methods After obtaining institutional review board approval, patients with parastomal hernia who underwent laparoscopic repair using Sugarbaker technique between 2009 and 2012 were compared to patients with ventral hernias who underwent LVH repair in a retrospective review, with a match of 1:3. Data collected included demographics, comorbidities, operative time, defect size, and mesh size. Outcomes and complications were compared between the two groups. Results Twenty patients underwent Sugarbaker repair, and these cases were compared to 60 patients with ventral hernia that received LVH repair. There was no statistically significant difference in age, BMI, smoking status, ASA & John Scott Roth [email protected] 1
Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, 800 Rose Street, UKMC C-222, Lexington, KY 40536-0298, USA
2
University of Kentucky, Lexington, KY, USA
score, defect size, or mesh size between groups. Operative time was significantly longer in the PH group: 172 ± 35 versus the LVH group: 94 ± 32 min (p \ 0.1). Length of stay was longer, 3 days (3–5.5) for PH versus 1 day (1–2.8) for LVH, p \ 0.1. The two groups did not differ in terms of wound complications or recurrence, with a median followup of 37 days (IQ range 27–518). Conclusion The Sugarbaker technique is as safe as LVH repair with no more complications given the presence of a stoma. Keywords Parastomal hernia Hernia repair Stoma Laparoscopic repair A parastomal hernia (PH) is an incisional hernia related to the presence of an abdominal wall stoma [1]. Parastomal hernias are the most common complication following stoma creation, occurring in up to 50 % of patients [2]. The majority of these hernias occur in the first 2 years after stoma construction. The presence of a parastomal hernia has been found to be associated with adverse effects on quality of life and psychological well-being and can place significant burdens on healthcare resources [3, 4]. Risk factors for PH include: emergently constructed ostomy, poor nutritional status, steroid use, abdominal obesity, any cause of increased intra-abdominal pressure, and wound infection. A majority of the patients with PH are asymptomatic and can be managed non-operatively. However, symptomatic patients report pain and discomfort associated with the hernia, and difficulty in maintaining seal of ostomy appliance with intestinal content leakage and resultant skin excoriation. PH can present similar to any other ventral hernia with bowel obstruction, incarceration, or strangulation leading to possible catastrophic outcomes.
123
Surg Endosc
There have been multiple different techniques for PH repair described including relocation of the stoma, and open or laparoscopic repair with or without mesh. Relocation of the stoma will result in a new weak point in the patient’s fascia and will add another defect from the newly created ostomy, without eliminating the primary reason for the development of the PH in the first place; therefore, this approach carries a high recurrence rate [5]. The two most common techniques for PH repair with mesh include the keyhole (KH) technique [6] and the Sugarbaker repair [7], with each having a laparoscopic version. In the KH technique, a piece of mesh is slit in one of the sides to be placed around the ostomy; however, this creates a weak point in the mesh that could lead to recurrence. In the Sugarbaker technique repair, a single uncut piece of mesh is inserted intraabdominally and a tunnel is created to lateralize the bowel, thus allowing the mesh to cover the abdominal wall defect. Laparoscopic repair of PHs utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes [8]. A polytetrafluoroethylene (PTFE) patch is the most common prosthesis used in this repair. The PTFE mesh is soft and pliable, resulting in less severe adhesions to intraabdominal viscera; however, in the presence of adhesions, dissection from the mesh can be easily accomplished [9]. Other characteristics of PTFE include the lack of ingrowth which makes it vulnerable to infection [10]; microorganisms can persist in the micropores of the material and may require mesh explantation as definitive treatment. The use of material such as polypropylene has the advantages of cost efficiency, good incorporation into the tissue, and general resistance to infection. In the case of infection, polypropylene mesh has a higher rate of salvage; unfortunately, this prosthesis cannot be placed intra-abdominally due to the formation of adhesions with intra-abdominal viscera and potential erosion into the bowel [11]. The problems associated with the use of synthetic mesh material have led to the use of biologic mesh, but recent review of the literature has shown no improvement in hernia recurrence rates or complications as compared to the use of synthetic materials [12]. Laparoscopic ventral hernia repair (LVH) is commonly performed. Recent studies have shown that using a laparoscopic approach to ventral hernia repair is safe and effective and is associated with a shorter hospital stay and lower incidence of recurrence when compared to an open approach [13]. When a laparoscopic modified Sugarbaker technique is used for repair of PH, the same principles of LVH repair should be applied, including the overlapping of mesh in relation to the abdominal wall defect and principles of mesh fixation. When a Sugarbaker technique is undertaken, it is mandatory that careful attention be paid at the time of creation of the lateral tunnel of intestine to avoid injury to the blood supply to the stoma and potential postoperative obstruction at the exit site. Some surgeons propose the use of
123
extra transfascial sutures in case a release of the tunnel is necessary in the early postoperative period. The presence of the existing stoma may have potential for increased risk of infection, and some surgeons have been hesitant to use prosthetic material to reinforce the repair. The purpose of this study was to compare outcomes in patients who underwent laparoscopic PH repair utilizing the Sugarbaker technique with patients who underwent conventional LVH repair.
Patients and methods With institutional review board approval, a retrospective review of existing data from 2009 to 2012 was performed for cases at a single institution of laparoscopic PH repair with a modified Sugarbaker technique in patients of a single surgeon compared to a group of patients (3:1 match) that underwent LVH repair with mesh implantation by the same surgeon during the same period of time. A propensity score was created by regressing variables against whether or not a LVH repair versus Sugarbaker technique was performed. The variables used for the regression included the following: age, gender, diabetes, CHF, COPD, asthma, cancer, coronary artery disease, hypertension, renal failure, smoking, BMI, ASA class, previous hernia repair, defect size, and size of mesh used for the repair. Once the two groups were matched (three LVH repair for each Sugarbaker repair), we compared results in terms of operative variable and outcomes. Preoperative patient characteristics included in the dataset were: age, gender, height, weight, BMI, smoking status, ASA classification, comorbidities (COPD, asthma, diabetes, coronary artery disease), and history of previous hernia repair. The perioperative data collected included the date of hernia repair, defect size, operative time in minutes, estimated blood loss, size of mesh, intraoperative complication(s), and length of stay. Postoperative data included incidence of length of time of follow-up, wound complications, pain scores, and hernia recurrence. Patients were seen in the office for follow-up, and recurrence of hernia was determined by physical examination or imaging studies when the surgeon considered necessary. Data were obtained from our electronic medical records. Statistical analysis was performed using Chi-square and Fisher’s exact test as appropriate. Statistical significance was assumed at p \ 0.05.
Results A total of 20 patients with a Sugarbaker repair were identified in our database. These cases were matched with 60 patients that had undergone LVH repair. Patient
Surg Endosc
demographic characteristics were similar between the two groups (Table 1). Fourteen female and six male patients underwent Sugarbaker repair, and thirty-eight females and twenty-two males were in the comparative LVH repair group. All patients were taken electively to the operating room for a hernia repair with implantation of mesh. Operative time was longer using Sugarbaker technique (172 ± 35 min) when compared to LVH repair (94 ± 32 min), p \ 0.01. Hospital length of stay was significantly greater in Sugarbaker repair than in LVH repair (3 days, interquartile range 2–5.5 days vs. 1 day, interquartile range 1–2.8 days, respectively, p \ 0.01). The size of the hernia defect (64 ± 55 cm in the PH group and 74 ± 65 cm in the LVH group) and the average size of mesh that was used (465 and 426, respectively Table 2), did not differ significantly. No major intraoperative complications occurred, and there were no conversions to open repair in our study group. The median time of follow-up for patients with PH was 502 days (interquartile range 33–778 days) with a minimum of 17 days and a maximum of 1294 days. The patients with LVH repair had a median follow-up of 36 days (interquartile range 23–317 days), with a minimum of 15 days and a maximum of 1435 days. For the two groups combined, the median time of follow-up of patients was 37 days (interquartile range 27–518 days). There were no statistical differences between groups for wound occurrences, including superficial surgical site infections or the presence of hematoma or seroma. There were no incidents of mesh infection in either group. There was one patient with hernia recurrence in the PH group and one patient with hernia recurrence in the LVH group (Table 3).
Discussion PH repair has been a challenging surgical problem since creation of stomas. The fact that a stoma is a controlled hernia in and of itself makes this subject interesting and Table 1 Preoperative patient characteristics
complicated. Many techniques and variations for surgical treatment of PH hernia have been developed with mixed results. The laparoscopic modified Sugarbaker technique has shown good results in terms of low incidence of complications and recurrence and is the method of choice in our practice to treat this condition [14]. The use of a prosthetic material in the presence of a stoma in a contaminated field has increased concern for mesh infection, and depending on the type of mesh used, explantation of the mesh could be necessary in case of infection, leading to multiple complications, and recurrence. It is important to choose the type of mesh based on the location of implantation. The use of biologic mesh for this purpose warrants further study for definitive conclusions, but preliminary results show no benefit compared to synthetic mesh with an increase in cost [12]. This operation is technically challenging; accessing the abdomen laparoscopically in and of itself could lead to enterotomies and therefore a change in plans. Creating the tunnel of the ostomy and mesh preparation also presents some difficulties. It is necessary to preserve the blood supply to the stoma, especially during lysis of adhesions, closing the parastomal defect, or when fixating the mesh, all of these factors making a PH repair more challenging than a traditional LVH repair. Patients with LVH repair may have complications related to the wound and related to the procedure itself. In the presence of a more complicated procedure such as PH repair, we expect to have more complications, especially in the presence of a contaminated field, wound complications may be expected to be higher. On the contrary, our data show that patients with Sugarbaker repair had similar complication and recurrence rates as patients having undergone LVH repair. The only difference between the two groups was in operative time and hospital stay, with no difference in outcome. Laparoscopic Sugarbaker repair has been shown to be superior to other methods for repair of PH [15] and shows no difference in terms of complications when compared to
Parastomal hernia repair
Ventral hernia repair
p value for difference
Number of patients
20
60
Age, mean year ± SD
64 ± 10
59 ± 13
0.09
BMI, mean kg/m2 ± SD
32 ± 6
31 ± 6
0.43
Smoker ASA class II
10 % 30 %
13 % 30 %
1.00 0.96
ASA class III
65 %
63 %
ASA class IV
5%
7%
Female
70 %
63 %
0.79
Diabetes
10 %
15 %
0.72
COPD/asthma
30 %
17 %
0.21
123
Surg Endosc Table 2 Perioperative variables Parastomal hernia repairs
Ventral hernia repairs
Number of patients
20
60
Operative duration, mean min ± SD
172 ± 35
94 ± 32
\0.01
Defect size, mean cm2 ± SD
64 ± 55
74 ± 65
0.55
Mesh size, mean cm ± SD
465 ± 171
426 ± 179
Length of hospital stay, median days (interquartile range)
3 (2–5.5)
1 (1–2.8)
2
Table 3 Patient outcomes
p value for difference
0.41 \0.01
Parastomal hernia repair (%)
Ventral hernia repair (%)
p value for difference
Wound complication
15
15
1.000
Seroma/hematoma
15
13
Superficial SSI
0
2
Pain
15
2
0.046
Recurrence
5
1.7
0.44
SSI surgical site infection
LVH repair. Sugarbaker repair requires more time than LVH repair, most likely because adhesions tend to be more extensive and the creation of the tunnel with mesh is timeconsuming. The longer length of stay for patients that underwent Sugarbaker repair was predominantly related to postoperative ileus that could be related to the extensive lysis of adhesions that is mandatory in Sugarbaker. Limitations of our study were the sample bias and the small number of patients in the Sugarbaker arm. We created a propensity score to compare this group to a group with similar demographic characteristics that underwent LVH repair, which also represented a selection bias. This was a retrospective review with short follow-up. It is important to emphasize the differences in the follow-up for each group; the patients with a PH usually had more comorbidities and ongoing medical needs that translated into a longer followup in our study. Alternatively, patients with a ventral hernia usually had a less complicated medical situation, and therefore, their follow-up period was generally shorter unless they presented with any complication related to the surgery. The short median duration of follow-up in the ventral incisional hernia repair group is inadequate to address recurrences beyond technical failures. Evaluating patients for hernia recurrence generally requires follow-up durations of at least one year, and longer durations are preferable. Follow-up in the parastomal hernia repair group, however, was approximately 16 months. Numerous prior studies have established the efficacy of laparoscopic ventral hernia repair as a durable procedure with low recurrence rates. This study demonstrates the similarities in both operative and short-term outcomes between laparoscopic ventral hernia repair and laparoscopic parastomal hernia
123
repair with the modified Sugarbaker technique. Long-term follow-up would be beneficial to further clarify the impact of the technique differences upon long-term hernia recurrence rate as this study only addressed the perioperative and shortterm complications. Nevertheless, we think this could represent an accurate trend in outcomes.
Conclusion Laparoscopic repair of PH utilizing a Sugarbaker technique may be safely performed with a low incidence of complications and recurrences. Hospital stay and operative duration are significantly longer in patients undergoing Sugarbaker repair than LVH repair, although this did not impact outcomes. Laparoscopic parastomal hernia repair using Sugarbaker technique results in similar perioperative outcomes as LVH repair, even in the presence of a stoma. Compliance with Ethical Standards Disclosures Dr. Levy, Ms. Plymale, Mr. Miller, and Dr. Davenport have no conflicts of interest or financial ties to disclose. Dr. Roth has received external Grant funding and consulting fees from CR Bard; he is on speaker bureaus for CR Bard and Ethicon; and he is a Board member of the Musculoskeletal Transplant Foundation. Funding
There was no funding for this project.
References 1. Pearl RK (1989) Parastomal hernias. World J Surg 13:569–572 2. Craft R, Harold K (2009) Laparoscopic repair of incisional and other complex abdominal well hernias. Perm J 13:38–42
Surg Endosc 3. Pringle W, Swan E (2001) Continuing care after discharge from hospital for stoma patients. Br J Nurs 10:1275–1288 4. Londono-Schimmer EE, Leong AP, Phillips RK (1994) Life table analysis of stomal complications following colostomy. Dis Colon Rectum 37:916–920 5. Safadi B (2004) Laparoscopic repair of parastomal hernia: early results. Surg Endosc 18:676–680 6. Birgitta ME, Hansson MD (2012) Surgical techniques for parastomal hernia repair: a systematic review of the literature. Ann Surg 255:685–695 7. Sugarbaker PH (1985) Peritoneal approach to prosthetic mesh repair of paracolostomy hernias. Ann Surg 201:344–346 8. Hansson E (2013) The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study. Surg Endosc 27:494–500 9. Wassenaar EB, Schoenmaeckers EJ, Raymakers JT, Rakic S (2010) Subsequent abdominal surgery after laparoscopic ventral and incisional hernia repair. Hernia 14:137–142 10. Bleichrodt RP, Simmermacher RK, van der Lei B, Schakenraad JM (1993) Expanded polytetrafluoroethylene patch versus
11.
12.
13.
14.
15.
polypropylene mesh for the repair of contaminated defects of the abdominal wall. Surg Gynecol Obstet 176:18–24 Kasperk R, Klinge U, Schumpelick V (2000) The repair of large parastomal hernias using a midline approach and a prosthetic mesh in the sublay position. Am J Surg 179:186–188 Slater NJ, Hansson BM, Buyne OR, Hendriks T, Bleichrodt RP (2011) Repair of parastomal hernias with biologic grafts: a systematic review. J Gastrointest Surg 15:1252–1258 Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 238:391–399 (discussion 399–400) Asif A, Ruiz M, Yetasook A, Denham W, Linn J, Carbray J, Ujiki M (2012) Laparoscopic modified Sugarbaker technique results in superior recurrence rate. Surg Endosc 26:3430–3434 Hoturas A, Murphy J, Thaha M, Chan CL (2013) The persistent challenge of parastomal herniation: a review of the literature and future developments. Colorectal Dis 15:e202–e214
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and Other Interventional Techniques
Laparoscopic parastomal hernia repair: No different than a laparoscopic ventral hernia repair? Salomon Levy1 • Margaret A. Plymale1 • Michael T. Miller2 • Daniel L. Davenport1 John Scott Roth1
•
Received: 14 January 2015 / Accepted: 22 June 2015 Ó Springer Science+Business Media New York 2015
Abstract Background Parastomal hernia (PH) is a common complication when a stoma is used. The high incidence (35–50 %) and patient longevity have created a situation where patients are being referred for consideration of repair with more frequency. Due to the presence of an ostomy and the increased bacterial contamination of the area, the insertion of a prosthetic material is concerning for complications. Laparoscopic repair of parastomal hernias utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes. The purpose of this study is to demonstrate that laparoscopic PH repair has outcomes similar to laparoscopic ventral hernia (LVH) repair without the presence of a stoma. Methods After obtaining institutional review board approval, patients with parastomal hernia who underwent laparoscopic repair using Sugarbaker technique between 2009 and 2012 were compared to patients with ventral hernias who underwent LVH repair in a retrospective review, with a match of 1:3. Data collected included demographics, comorbidities, operative time, defect size, and mesh size. Outcomes and complications were compared between the two groups. Results Twenty patients underwent Sugarbaker repair, and these cases were compared to 60 patients with ventral hernia that received LVH repair. There was no statistically significant difference in age, BMI, smoking status, ASA & John Scott Roth [email protected] 1
Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, 800 Rose Street, UKMC C-222, Lexington, KY 40536-0298, USA
2
University of Kentucky, Lexington, KY, USA
score, defect size, or mesh size between groups. Operative time was significantly longer in the PH group: 172 ± 35 versus the LVH group: 94 ± 32 min (p \ 0.1). Length of stay was longer, 3 days (3–5.5) for PH versus 1 day (1–2.8) for LVH, p \ 0.1. The two groups did not differ in terms of wound complications or recurrence, with a median followup of 37 days (IQ range 27–518). Conclusion The Sugarbaker technique is as safe as LVH repair with no more complications given the presence of a stoma. Keywords Parastomal hernia Hernia repair Stoma Laparoscopic repair A parastomal hernia (PH) is an incisional hernia related to the presence of an abdominal wall stoma [1]. Parastomal hernias are the most common complication following stoma creation, occurring in up to 50 % of patients [2]. The majority of these hernias occur in the first 2 years after stoma construction. The presence of a parastomal hernia has been found to be associated with adverse effects on quality of life and psychological well-being and can place significant burdens on healthcare resources [3, 4]. Risk factors for PH include: emergently constructed ostomy, poor nutritional status, steroid use, abdominal obesity, any cause of increased intra-abdominal pressure, and wound infection. A majority of the patients with PH are asymptomatic and can be managed non-operatively. However, symptomatic patients report pain and discomfort associated with the hernia, and difficulty in maintaining seal of ostomy appliance with intestinal content leakage and resultant skin excoriation. PH can present similar to any other ventral hernia with bowel obstruction, incarceration, or strangulation leading to possible catastrophic outcomes.
123
Surg Endosc
There have been multiple different techniques for PH repair described including relocation of the stoma, and open or laparoscopic repair with or without mesh. Relocation of the stoma will result in a new weak point in the patient’s fascia and will add another defect from the newly created ostomy, without eliminating the primary reason for the development of the PH in the first place; therefore, this approach carries a high recurrence rate [5]. The two most common techniques for PH repair with mesh include the keyhole (KH) technique [6] and the Sugarbaker repair [7], with each having a laparoscopic version. In the KH technique, a piece of mesh is slit in one of the sides to be placed around the ostomy; however, this creates a weak point in the mesh that could lead to recurrence. In the Sugarbaker technique repair, a single uncut piece of mesh is inserted intraabdominally and a tunnel is created to lateralize the bowel, thus allowing the mesh to cover the abdominal wall defect. Laparoscopic repair of PHs utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes [8]. A polytetrafluoroethylene (PTFE) patch is the most common prosthesis used in this repair. The PTFE mesh is soft and pliable, resulting in less severe adhesions to intraabdominal viscera; however, in the presence of adhesions, dissection from the mesh can be easily accomplished [9]. Other characteristics of PTFE include the lack of ingrowth which makes it vulnerable to infection [10]; microorganisms can persist in the micropores of the material and may require mesh explantation as definitive treatment. The use of material such as polypropylene has the advantages of cost efficiency, good incorporation into the tissue, and general resistance to infection. In the case of infection, polypropylene mesh has a higher rate of salvage; unfortunately, this prosthesis cannot be placed intra-abdominally due to the formation of adhesions with intra-abdominal viscera and potential erosion into the bowel [11]. The problems associated with the use of synthetic mesh material have led to the use of biologic mesh, but recent review of the literature has shown no improvement in hernia recurrence rates or complications as compared to the use of synthetic materials [12]. Laparoscopic ventral hernia repair (LVH) is commonly performed. Recent studies have shown that using a laparoscopic approach to ventral hernia repair is safe and effective and is associated with a shorter hospital stay and lower incidence of recurrence when compared to an open approach [13]. When a laparoscopic modified Sugarbaker technique is used for repair of PH, the same principles of LVH repair should be applied, including the overlapping of mesh in relation to the abdominal wall defect and principles of mesh fixation. When a Sugarbaker technique is undertaken, it is mandatory that careful attention be paid at the time of creation of the lateral tunnel of intestine to avoid injury to the blood supply to the stoma and potential postoperative obstruction at the exit site. Some surgeons propose the use of
123
extra transfascial sutures in case a release of the tunnel is necessary in the early postoperative period. The presence of the existing stoma may have potential for increased risk of infection, and some surgeons have been hesitant to use prosthetic material to reinforce the repair. The purpose of this study was to compare outcomes in patients who underwent laparoscopic PH repair utilizing the Sugarbaker technique with patients who underwent conventional LVH repair.
Patients and methods With institutional review board approval, a retrospective review of existing data from 2009 to 2012 was performed for cases at a single institution of laparoscopic PH repair with a modified Sugarbaker technique in patients of a single surgeon compared to a group of patients (3:1 match) that underwent LVH repair with mesh implantation by the same surgeon during the same period of time. A propensity score was created by regressing variables against whether or not a LVH repair versus Sugarbaker technique was performed. The variables used for the regression included the following: age, gender, diabetes, CHF, COPD, asthma, cancer, coronary artery disease, hypertension, renal failure, smoking, BMI, ASA class, previous hernia repair, defect size, and size of mesh used for the repair. Once the two groups were matched (three LVH repair for each Sugarbaker repair), we compared results in terms of operative variable and outcomes. Preoperative patient characteristics included in the dataset were: age, gender, height, weight, BMI, smoking status, ASA classification, comorbidities (COPD, asthma, diabetes, coronary artery disease), and history of previous hernia repair. The perioperative data collected included the date of hernia repair, defect size, operative time in minutes, estimated blood loss, size of mesh, intraoperative complication(s), and length of stay. Postoperative data included incidence of length of time of follow-up, wound complications, pain scores, and hernia recurrence. Patients were seen in the office for follow-up, and recurrence of hernia was determined by physical examination or imaging studies when the surgeon considered necessary. Data were obtained from our electronic medical records. Statistical analysis was performed using Chi-square and Fisher’s exact test as appropriate. Statistical significance was assumed at p \ 0.05.
Results A total of 20 patients with a Sugarbaker repair were identified in our database. These cases were matched with 60 patients that had undergone LVH repair. Patient
Surg Endosc
demographic characteristics were similar between the two groups (Table 1). Fourteen female and six male patients underwent Sugarbaker repair, and thirty-eight females and twenty-two males were in the comparative LVH repair group. All patients were taken electively to the operating room for a hernia repair with implantation of mesh. Operative time was longer using Sugarbaker technique (172 ± 35 min) when compared to LVH repair (94 ± 32 min), p \ 0.01. Hospital length of stay was significantly greater in Sugarbaker repair than in LVH repair (3 days, interquartile range 2–5.5 days vs. 1 day, interquartile range 1–2.8 days, respectively, p \ 0.01). The size of the hernia defect (64 ± 55 cm in the PH group and 74 ± 65 cm in the LVH group) and the average size of mesh that was used (465 and 426, respectively Table 2), did not differ significantly. No major intraoperative complications occurred, and there were no conversions to open repair in our study group. The median time of follow-up for patients with PH was 502 days (interquartile range 33–778 days) with a minimum of 17 days and a maximum of 1294 days. The patients with LVH repair had a median follow-up of 36 days (interquartile range 23–317 days), with a minimum of 15 days and a maximum of 1435 days. For the two groups combined, the median time of follow-up of patients was 37 days (interquartile range 27–518 days). There were no statistical differences between groups for wound occurrences, including superficial surgical site infections or the presence of hematoma or seroma. There were no incidents of mesh infection in either group. There was one patient with hernia recurrence in the PH group and one patient with hernia recurrence in the LVH group (Table 3).
Discussion PH repair has been a challenging surgical problem since creation of stomas. The fact that a stoma is a controlled hernia in and of itself makes this subject interesting and Table 1 Preoperative patient characteristics
complicated. Many techniques and variations for surgical treatment of PH hernia have been developed with mixed results. The laparoscopic modified Sugarbaker technique has shown good results in terms of low incidence of complications and recurrence and is the method of choice in our practice to treat this condition [14]. The use of a prosthetic material in the presence of a stoma in a contaminated field has increased concern for mesh infection, and depending on the type of mesh used, explantation of the mesh could be necessary in case of infection, leading to multiple complications, and recurrence. It is important to choose the type of mesh based on the location of implantation. The use of biologic mesh for this purpose warrants further study for definitive conclusions, but preliminary results show no benefit compared to synthetic mesh with an increase in cost [12]. This operation is technically challenging; accessing the abdomen laparoscopically in and of itself could lead to enterotomies and therefore a change in plans. Creating the tunnel of the ostomy and mesh preparation also presents some difficulties. It is necessary to preserve the blood supply to the stoma, especially during lysis of adhesions, closing the parastomal defect, or when fixating the mesh, all of these factors making a PH repair more challenging than a traditional LVH repair. Patients with LVH repair may have complications related to the wound and related to the procedure itself. In the presence of a more complicated procedure such as PH repair, we expect to have more complications, especially in the presence of a contaminated field, wound complications may be expected to be higher. On the contrary, our data show that patients with Sugarbaker repair had similar complication and recurrence rates as patients having undergone LVH repair. The only difference between the two groups was in operative time and hospital stay, with no difference in outcome. Laparoscopic Sugarbaker repair has been shown to be superior to other methods for repair of PH [15] and shows no difference in terms of complications when compared to
Parastomal hernia repair
Ventral hernia repair
p value for difference
Number of patients
20
60
Age, mean year ± SD
64 ± 10
59 ± 13
0.09
BMI, mean kg/m2 ± SD
32 ± 6
31 ± 6
0.43
Smoker ASA class II
10 % 30 %
13 % 30 %
1.00 0.96
ASA class III
65 %
63 %
ASA class IV
5%
7%
Female
70 %
63 %
0.79
Diabetes
10 %
15 %
0.72
COPD/asthma
30 %
17 %
0.21
123
Surg Endosc Table 2 Perioperative variables Parastomal hernia repairs
Ventral hernia repairs
Number of patients
20
60
Operative duration, mean min ± SD
172 ± 35
94 ± 32
\0.01
Defect size, mean cm2 ± SD
64 ± 55
74 ± 65
0.55
Mesh size, mean cm ± SD
465 ± 171
426 ± 179
Length of hospital stay, median days (interquartile range)
3 (2–5.5)
1 (1–2.8)
2
Table 3 Patient outcomes
p value for difference
0.41 \0.01
Parastomal hernia repair (%)
Ventral hernia repair (%)
p value for difference
Wound complication
15
15
1.000
Seroma/hematoma
15
13
Superficial SSI
0
2
Pain
15
2
0.046
Recurrence
5
1.7
0.44
SSI surgical site infection
LVH repair. Sugarbaker repair requires more time than LVH repair, most likely because adhesions tend to be more extensive and the creation of the tunnel with mesh is timeconsuming. The longer length of stay for patients that underwent Sugarbaker repair was predominantly related to postoperative ileus that could be related to the extensive lysis of adhesions that is mandatory in Sugarbaker. Limitations of our study were the sample bias and the small number of patients in the Sugarbaker arm. We created a propensity score to compare this group to a group with similar demographic characteristics that underwent LVH repair, which also represented a selection bias. This was a retrospective review with short follow-up. It is important to emphasize the differences in the follow-up for each group; the patients with a PH usually had more comorbidities and ongoing medical needs that translated into a longer followup in our study. Alternatively, patients with a ventral hernia usually had a less complicated medical situation, and therefore, their follow-up period was generally shorter unless they presented with any complication related to the surgery. The short median duration of follow-up in the ventral incisional hernia repair group is inadequate to address recurrences beyond technical failures. Evaluating patients for hernia recurrence generally requires follow-up durations of at least one year, and longer durations are preferable. Follow-up in the parastomal hernia repair group, however, was approximately 16 months. Numerous prior studies have established the efficacy of laparoscopic ventral hernia repair as a durable procedure with low recurrence rates. This study demonstrates the similarities in both operative and short-term outcomes between laparoscopic ventral hernia repair and laparoscopic parastomal hernia
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repair with the modified Sugarbaker technique. Long-term follow-up would be beneficial to further clarify the impact of the technique differences upon long-term hernia recurrence rate as this study only addressed the perioperative and shortterm complications. Nevertheless, we think this could represent an accurate trend in outcomes.
Conclusion Laparoscopic repair of PH utilizing a Sugarbaker technique may be safely performed with a low incidence of complications and recurrences. Hospital stay and operative duration are significantly longer in patients undergoing Sugarbaker repair than LVH repair, although this did not impact outcomes. Laparoscopic parastomal hernia repair using Sugarbaker technique results in similar perioperative outcomes as LVH repair, even in the presence of a stoma. Compliance with Ethical Standards Disclosures Dr. Levy, Ms. Plymale, Mr. Miller, and Dr. Davenport have no conflicts of interest or financial ties to disclose. Dr. Roth has received external Grant funding and consulting fees from CR Bard; he is on speaker bureaus for CR Bard and Ethicon; and he is a Board member of the Musculoskeletal Transplant Foundation. Funding
There was no funding for this project.
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