LAPAROCELI: LAPAROSCOPY LIVE SURGERY PARASTOMAL HERNIA: WHAT TO DO? OSPEDALE DI PORTOGRUARO U.O.C. CHIRURGIA GENERALE FRANCESCO FIDANZA

Transcription

1 LAPAROCELI: LAPAROSCOPY LIVE SURGERY PARASTOMAL HERNIA: WHAT TO DO? OSPEDALE DI PORTOGRUARO U.O.C. CHIRURGIA GENERALE FRANCESCO FIDANZA

2 PARASTOMAL HERNIA Some degree of herniation around a colostomy is so common that this complication may be regarded as inevitable ( Goligher) It doesn t matter if God Himself made your ostomy. If you have it long enough you have a 100% risk of a parastomal hernia (J Byron Galthright)

3 MAGNITUDE OF THE PROBLEM Between and intestinal stomas (ileostomy and colostomy) are created each year Approximately 1/2 will be permanent stomas 30-50% of these ( ) will develop parastomal hernias wich will require surgical repair

4 PARASTOMAL HERNIA RISK FACTORS Patient factors Age Intra abdominal pressure factors Obesity Emphysema

5 PARASTOMAL HERNIA RISK FACTORS Wound healing factors Infection Steroids / Immune modulators Genetics (collagen deficiency)

6 PARASTOMAL HERNIA RISK FACTORS Mistakes in surgical technique Site outside of rectus sheath Stoma defect created too large

7 SYMPTOMS OF PARASTOMAL HERNIA Protrusion of stoma beyond abdominal wall Prolapse of stoma Enlargement of stoma Severe parastomal skin irritation Severe parastomal pain Incarceration or strangulation

8 HERNIA CONFIR MEDD ABSOLUTE INDICATIO N FOR SURGERY MAYOR SYMPTOM S MINOR SYMPTOM S CONTRAIND ICATION FOR SURGERY LOCAL REPAIR LOCAL REPAIR WITH MESH RE- LOCATI ON symptoms CONSERV ATIVE CARE

9 TREATMENT The best treatment for a parastomal hernia is, of course, reversal of the ostomy (when it is possible) Carne PWG, Robertson GM, Frittelle FA Parastomal hernia Br J Surg 2009 The open approaches to repair of parastomal hernias include primary fascial repair, repair with mesh, and stoma relocation. Primary fascial repair, although technically simple, carries a recurrence rate of up to 50%. Allen-Marsh TG, Thomson JP. Surgical treatment of colostomy complications Br J Surg 1998

10 NON-MESH TECHNIQUE Takedown Primary suture repair is unacceptable Stoma resite results in 3 potential hernias Midline incision Old stoma site Parastomal at new site

11 OPEN ONLAY Easy to reduce hernia Difficult to lyse adhesions Large peri-wound cavity Wound complications Difficult for Patient to care for ostomy postop Via Midline Difficult in obese pts Can devascularize tissue Recurrence up to 26% Steele SR. Am J sunrg 2003 v

12 OPEN REPAIR RESULTS Author No. of pts Material Results Steele, Polypro mesh 26% recurrence; 9% SBO; 3% prolapse; 3% wound inf.; 3% fistula; 2% mesh erosion Stelzner, PTFE 3/20 recurred at 3.5 years Longman, Polypro No recurrences or infections at 30 months

13 SURGICAL LAPAROSCOPIC TECHNIQUES It was not until 1998 when Percheron et Al described the first laparoscopic repair of parastomal hernias as a possible solution to this common problem

14 LAPAROSCOPIC SURGERY The most difficult of any laparoscopic parastomal hernia repair is the safe division of adhesions Favorable factors for successful laparoscopic approach to bowel surgery Prior laparoscopic surgery Fewer than 2 prior surgeries Milder abdominal distension Pliable abdominal wall Lack of mesh Lack of enterocutaneous fistula

15 LAPAROSCOPIC SURGERY The mesh can be formatted on the basis of either of 2 main principles. The modified Sugarbaker technique with a nonslit mesh covering the hernia defect with at least a 5-cm overlap with lateralization of the colon/ileum going into the stoma. The keyhole technique, where a hole is cut out to encircle the stoma with a slit and the mesh covers the hernia around the bowel. Hanson BM, Slater NJ, Van der Velden AS, et Al. Surgical techniques for parastomal hernia repair: a systematic review of the literature. Ann. Surg. 2012; 255(4):

16 O.R. SET-UP K. Harold Operative Tecniques in Gen. Surg. 2007

17 SUGARBAKER TECHNIQUE K. Harold Operative Tecniques in Gen. Surg. 2007

18 ADHESIOLYSIS

19 SUGARBAKER (EXITING SIDE OF MESH)

20 Fascial defect SUGARBAKER Stoma bowel exiting side

21 OUTCOMES LAP PARASTOMAL HERNIA REPAIR (SUGARBAKER TECHNIQUE) Patient Characteristics (N=21) Mean age (yr) 66 (36-82) Mean defect size (cm 2 ) 130 (25-416) Mean mesh size (cm 2 ) 440 ( ) Mean operative time (mins) 210 (99-326) Mean L.O.S. (days) 6 (2-14) Mean follow up (months) 20 (6-36) Laparoscopic success rate 100% Recurrences 1 (5%) Complications K. Harold 10 et al. (50%) Hernia 2007 Nov

22 KEYHOLE TECNIQUE K. Harold Operative Tecniques in Gen. Surg. 2007

23 KEYHOLE TECNIQUE

24 OUTCOMES LAP PARASTOMAL REPAIR 55 patients Keyhole technique 85% completed laparoscopically Mean LOS 4 days 6 enterotomies 2 mesh infx 36 mo f/u (12-72mo) 20 recurrences (37%) Hansson, BM et al., Surg Endosc July

25 KEYHOLE VS. SUGARBAKER (LAP) (LITERATURE REVIEW) Repair type No. pts (60) O.R. time (min) LOS Comp. % Recur. % Keyhole % (0-33%) 27% (0-44%) Sugarbaker % (0-25%) 16%(0-19%) K. Harold et al. Presented American Hernia Society 2006

26 PREVENTION OF PARASTOMAL HERNIAS

27 PROPHYLACTIC MESH There has been a flurry of interest to reinforce the abdominal wall with a piece of mesh every time a stoma is made. Studies have shown cost-effectiveness in placing a mesh prophylactically in those patients requiring a permanent stoma Lee L, Saleem A, Landry T, Latimer E, Chaudhury P, Felman LS. Cost effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing permanent colostomy for rectal cancer. J Am Coll Surg 2014

28 PROPHYLACTIC MESH A STUDY OF MAYO CLINIC I want to show you a study done at Mayo Clinic on prophylactic positioning of a mesh during the packaging of a stoma

29 RESULTS Mesh (16) No Mesh (23) O.R. Time (min) Ave Blood Loss (ml) Length of Stay (days) 10 (5-17) 9.6 (6-25) F/U (months) 17.5 (3-34) 17.1 (4-36) Hernia 1 (6%) 7 (31%)

30 RESULTS EIGHT PTS (31 %) WITH A STANDARD STOMA FORMATION DEVELOPED A HERNIA ONE PT (6 %) WITH MESH REINFORCEMENT DEVELOP A HERNIA P =.029 WITHOUT HERNIA PTS WITH HERNIA PTS REINFORCE MENT PTS WITHOUT MESH

31 FOLLOW UP 5 3,75 2,5 standard stoma formation without mesh stoma formation with mesh reinforcement 1,25 0

32 COMPLICATIONS Mesh Group 1 patient required postop transfusion of anemia No mesh related complications No Mesh Group 3 patients with ileus 1 patient with CHF 1 patient with pelvic abscess

33 CONCLUSIONS Lap parastomal hernia repair is feasible Results appear to be better than open repair Technique is demanding Sugarbaker easier / faster than Keyhole Prevention may be the best answer

34 OUR BEST CHOICE In these years we experimented both techniques: modified Sugarbacker keyhole technique BUT THE TECHNIQUE WE PREFER IS

35 THANK YOU VERY MUCH! OSPEDALE DI PORTOGRUARO U.O.C. CHIRURGIA GENERALE FRANCESCO FIDANZA