Laparoscopic repair of paraostomy hernias: early results.

Abstract

The paracolostomy hernia represents one of the difficult challenges for the hernia surgeon. The creation of the fascial defect to create the ostomy predisposes the patient to this problem. Other mitigating factors include many comorbid conditions such as obesity, diabetes mellitus, steroid usage, age, and so forth. There have been many attempts to provide a permanent solution to this hernia, many of which do not result in a long-lasting and satisfactory result. These have included the sutured repair of the defect itself, the prosthetic repair of the defect, and the relocation of the ostomy. The repair, whether open or laparoscopic, is necessitated by poor function of the ostomy, a poorly fitting appliance, obstruction, or the cosmetic deformity that accompanies the larger defects with a large hernia content. These problems are not limited to the colostomy hernia but will also be seen in the patient with a paraileostomy hernia. The primary or prosthetic repair of the hernia defect usually has a greater appeal to the patient, because the patient has become familiar with the ostomy at that location, and the use of the appliance is preferred in that location. On the other hand, many surgeons believe that the location of the ostomy must be changed to effect a long-lasting result. In either case, the operation is traditionally performed with a laparotomy. There have been a few reports of successful laparoscopic repair of paracolostomy hernias. Based on the success we have had with the laparoscopic repair of incisional and ventral hernias, we also believe that this methodology can be used effectively for the repair of paraostomy hernias. Three of these cases are presented in this report. TECHNIQUES Patient 1 This patient has been a long-standing patient of one of the authors. In August 1994, at the age of 71 years, she underwent a laparoscopically assisted abdominoperineal resection for rectal adenocarcinoma. She presented with a symptomatic paracolostomy hernia in April 1995. She underwent an open repair of this defect with nonabsorbable sutures in May 1995. In that repair, the fascial defect was repaired to approximate the size of the colon, and the colon was sutured to the fascial ring. This surgery eliminated the patient’s symptoms until 1998, when she presented with a partial colonic obstruction secondary to a recurrent hernia at the colostomy site. This was treated conservatively, with resolution without surgical intervention. She declined surgical intervention at that time. The patient then presented to the office with an enlarging hernia at the site of the colostomy in October 2000. Because this hernia prevented an adequate seal of the ostomy appliance, she desired surgery. At the time of this examination, she was noted to have a broad laxity of the abdominal wall adjacent to the colostomy in addition to the herniation of intraabdominal viscera. That is, her abdominal wall musculature was quite lax at this site in addition to the hernia deformity. Because she desired to maintain the location of the ostomy and because an earlier nonprosthetic repair had failed, we elected to repair this with the laparoscopic method. A standard bowel prep was administered before surgery. Her abdominal wall was draped with an iodineimpregnated plastic drape. Perioperative antibiotics were also administered. The abdomen was entered with the Optiview trocar (Ethicon Endosurgery, Inc., Cincinnati, OH). The location of the trocars that is typical for these procedures is shown in Figure 1. Several adhesions of omentum and small bowel were lysed to expose the hernia defect (Fig. 2). The colon was located superiolaterally in the fascial Dr LeBlanc is a member of the Speaker’s Bureau for WL Gore and Associates.