Parastomal Hernia Research Articles

Single-stage abdominal wall reconstruction in contaminated and dirty wounds is safe: a single center experience.

The proper approach to repair of complex abdominal wall hernia in contaminated and dirty surgical fields is unknown. Identification of a surgical approach limiting the number of operative procedures, post-operative complications, and financial burden is needed. We hypothesized that single-stage abdominal wall reconstruction using poly-4-hydroxybutyrate resorbable mesh would result in low incidence of post-operative surgical site occurrence and a low incidence of hernia recurrence in Centers for Disease Control class III and IV wounds. We conducted a single institution, retrospective cohort study of consecutive patients, age greater than 18years old, that underwent abdominal wall reconstruction complicated by presence of Centers for Disease Control class III and IV wounds between January 2014 and March 2019. Primary outcomes assessed were surgical site occurrence, hernia recurrence, and mesh-related adverse events. Thirty-four patients that underwent single-stage abdominal wall reconstruction utilizing poly-4-hydroxybutyrate mesh with contaminated (n = 12) and dirty/infected wounds (n = 22) were identified. Patients mean age was 64years, and body mass index was 31kg/m2. Mean follow-up was 37months, range of 21-60. Concurrent procedures included fistula takedown (n = 9), infected mesh removal (n = 6), and parastomal hernia repair (n = 6). Mean defect size was 150.7 cm2. Surgical site occurrence rate was 12%, with 1 superficial and 2 deep surgical site infections. Midline hernia recurrence rate was 0, there were two parastomal hernia recurrences, for an overall hernia recurrence rate of 6%. No mesh-related adverse events occurred. This study suggests that over a 3-year follow-up period single-stage complex abdominal wall reconstruction with poly-4-hydroxybutyrate is safe and durable. Single-stage complex abdominal wall reconstruction with poly-4-hydroxybutyrate mesh in the setting of Centers for Disease Control class III and IV wounds is a realistic option with acceptable outcomes.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Parastomal hernias and information retention: how and when to educate ostomates on risk minimisation

Background: Parastomal herniation is a common complication of stoma formation, caused by protrusion of the bowel through the abdominal wall, with a major negative impact on quality of life. Stoma care nurses should educate ostomates on how to minimise the risk of a parastomal hernia. However, new ostomates must absorb so much pre- and postoperative information that some of it may be missed, misunderstood or forgotten. Aims: A survey was conducted to determine how much information about parastomal hernias and risk minimisation patients remember, as well as the best way and time to deliver this information, including how often it should be repeated. Method: The survey comprised 13 multiple-choice questions and was distributed to adults with any type of stoma through medical equipment supplier SecuriCare Medical's postal mailing list and social media pages. These results were compared with findings from the literature. Findings: Of 544 participants, most were over 70 years old (55.2%) and had had a stoma for more than 10 years (59.1%). Of these, 70.6% had heard of parastomal hernias and 29.4% had not. Most of those who had heard of parastomal herniation heard of it when they were diagnosed with the complication (37.3%). Only 9.8% first heard of it from a stoma care nurse. Of those who had discussed herniation with a nurse, the largest group (26.4%) had done so at a postoperative home visit or clinic appointment. Conclusion: Those who have had their stoma for a long time are particularly likely to have never been educated on parastomal herniation or forgotten what they had learned, so are a priority for patient education. This education should be tailored to a patient's age, learning style and ability to process information in a short period, as well as anxiety level. Stoma care nurses should be careful to limit their use of jargon, abbreviations and the passive voice, as well as the amount and type of information being delivered. Such education should be delivered early and then repeated at regular intervals.

Modified Stapled Mesh Stoma Reinforcement Technique (SMART) for parastomal hernias, with video.

Modified Stapled Mesh Stoma Reinforcement Technique (SMART) for parastomal hernias, with video.

How-I-do-it: minimally invasive repair of ileal conduit parastomal hernias.

Parastomal hernia after radical cystectomy and ileal conduit urinary diversion is an underestimated and undertreated condition with significant impact on quality of life. However, its surgical treatment is challenging and prone to complications and the optimal surgical treatment of this condition remains to be determined. In this article, we describe our surgical techniques in the minimally invasive treatment of ileal conduit parastomal hernia and present our preliminary results. In a retrospective single-center design, a prospectively maintained database was screened. Data from all patients undergoing surgical treatment for a parastomal hernia after cystectomy and ileal conduit urinary diversion in our center were collected. Between May 2016 and June 2020, 15 patients underwent minimally invasive repair of a parastomal hernia of an ileal conduit. Details on the surgical approach are provided, along with a flow chart to standardize the choice of surgical technique, depending on the presence of a concomitant midline incisional hernia and perioperative findings. The majority of patients were treated with robotic-assisted laparoscopic surgery (10/15; 66.7%). Median postoperative hospital stay was 5days. One-third of patients developed a postoperative urinary infection. Median follow-up was 366days. One patient developed a local recurrence of her parastomal hernia on day 66 postoperatively, treated with intraperitoneal mesh. The minimally invasive surgical treatment of a parastomal hernia after ileal conduit urinary diversion poses specific perioperative challenges that require a broad surgical armamentarium and a tailored approach. Preliminary results confirm a significant morbidity after this type of surgery.

A giant parastomal hernia with partial herniation of the right kidney.

A giant parastomal hernia with partial herniation of the right kidney.

An Analysis of the Risk Factors for the Development of Parastomal Hernia: A Single Institutional Experience.

Objectives: To study the frequency of risk factors affecting the development of parastomal hernias in patients undergoing stoma formation.Study Design: A retrospective descriptive cross-sectional study.Duration of Study: This study was conducted at the Department of General Surgery between January 2017 to December 2020.Methodology: A total of 163 patients aged between 20 and 100 years and who required a stoma formation were included in the study. The patients with incomplete data and those lacking post-operative imaging were excluded. According to this selection criteria, 80 patients were excluded. The data was collected for all patients from the hospital database. This included patient’s demographic information, co-morbidities, pre-surgery patient characteristics, an indication of stoma formation, the location of stoma exit, type of surgery, associated comorbidities, subcutaneous fat thickness, and type of stoma formed. Data were analyzed using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.Results: The mean age was 68.46 ± 16.50 years, with males in the majority: 48 (57.8%). Most of the patients, 53 (63.8%), had malignant disease. Post-stoma formation, a total of 38 (45.9%) patients developed parastomal hernias, mostly involving the sigmoid colon (n=62, 74.7%). However, there was a statistically significant relationship between paroxysmal sympathetic hyperactivity (PSH) incidence with non-trans-rectus stomas (trans-oblique n=07, junctional n=28) (OR 3.04, CI 1.23-7.5, p=0.014). Furthermore, malignancy was also not an independent predictor of PSH (OR 0.408, CI 0.15-1.2, p=0.056). All other risk factors included in this study were nonsignificant.Conclusion: Our study shows that the incidence of parastomal hernias is rising with a high rate demonstrated in our patients. There was no statistically significant association between patient-related preoperative and operative factors with increased risk of parastomal hernias in our population except for a non-trans-rectus stoma, which was identified as an independent risk factor for parastomal hernias. Based on our findings, we would recommend a trans-rectus stoma over all other stoma sites. However, a much larger study is needed to validate this finding further.

Neonatal Enterostomies; Evaluation with Complications and Mortality

Aim The aim of this study is to evaluate the neonatal enterostomies performed in our clinic in the last 7 years and to discuss the complications, mortality and the causative factors. Materials and Methods From January 2015 to September 2021, 34 newborns who underwent enterostomy procedure as part of the treatment for a variety of intestinal disorders, medical records were reviewed retrospectively for birth week, birth weight, gender, primary disease, type of stoma, age at stoma closure, complications and mortality. Results Of 34 patients, 12 were female (35.3%) and 22 were male (64.7%). The mean birth weight of the patients was 2602 g (±927 g), and the average week of birth was 36 weeks (±3.2). Ileostomy was performed in 14 patients (41.2%), and colostomy was performed in 20 patients. Hirschprung’s disease is the commonest bowel anomaly with 13 patient (38.2%) requiring enterostomy and second anomaly is anorectal malformation with 8 patient (23.5%). Complications developed in 5 patients (14.7%); 4 prolapse, 1 parastomal hernia. A statistically significant difference was found in the development of complications when birth weights were compared (p=0.038). Mortality developed in 5 patients (14.7%). When the week of birth was compared in terms of mortality, a significant difference was found between them (p=0.033). Conclusions Enterostomy is usually a temporary procedure in neonates and is closed when the primary disease is corrected. Considering the high risk of prolapse in infants with low birth weight, maximum care should be exercised when opening an enterostomy.

Risk factors for the development of a parastomal hernia in patients with enterostomy: a systematic review and meta-analysis.

Parastomal hernia (PSH) is a common and serious complication in patients with enterostomy, but there is no current consensus for the risk factors for PSH from previous studies. Therefore, this study systematically analyzed the risk factors for PSH to provide a reference for prevention and treatment of this condition. Seven databases and 3 registers were systematically searched from database inception to January, 2021. Study quality was assessed by Newcastle-Ottawa Scale. Review Manager 5.3 software was used for statistical analysis. The data that could not be combined quantitatively were only analyzed qualitatively. Sixteen studies with 2031 patients were included. Higher BMI (OR, 1.29; 95% CI,1.02-1.63), older age (OR, 1.04; 95% CI, 1.02-1.07), female (OR, 2.55; 95% CI,1.39-4.67), lager aperture size (OR, 2.8; 95%CI, 1.78-4.42), transperitoneal stoma creation (OR, 2.4; 95% CI, 1.33-4.35), and lager waist circumference (OR, 1.01; 95% CI,1.0-1.01) were significant risk factors for PSH. The laparoscopic approach was not a risk factor for PSH (OR, 2.09; 95% CI, 0.83-5.27). Other risk factors, including the thickness of abdominal subcutaneous fat, no mesh, a stoma not through the middle of the rectus abdominis, atrophy of left lower medial part of rectus abdominis, α1(III) procollagen expression level, emergency surgery, no preoperative stoma site marking, end colostomy, smoking, diabetes, peristomal infection, severe abdominal distention, severe cough, chronic obstructive pulmonary disease, operation time and hypertension, were significant on the multivariate analysis of each individual study. The current available evidence showed that higher BMI, older age, female, larger aperture size, the creation of a transperitoneal stoma, and a larger waist circumference were independent risk factors for PSH. For factors without exact cutoff value, further explorations are needed in the future. In addition, reference to the limited number of studies in the pooled analysis, these factors still need to be interpreted carefully.

Comparison of postoperative complication rates between a novel endoluminal balloon-assisted drainage and diverting stoma after low rectal cancer.

To introduce a novel endo-luminal balloon-assisted drainage (EBAD) and compare postoperative complication rates between EBAD and diverting stoma (DS) groups. The single center prospective non-random cohort study included a total of 163 patients in convenience patients with rectal cancer between January 2019 and January 2021. Out of 163 patients, 83 underwent DS and 80 EBAD. Primary endpoints were postoperative complication rate. The total number of complications was 28 in the DS group vs. 22 in the EBAD group (P = 0.388). 18 patients (21.7%) in the DS group and 14 patients (17.5%) in the EBAD group developed postoperative complication (P = 0.501). There were no differences identified for anastomotic leak rates between the two groups (P = 0.677). The rate of the pelvic abscess was lower in the EBAD group (1/80, 1.3%) than in the DS group (4/83, 4.8%) but with no statistical significance (P = 0.386). Compared with the DS group, the median operative time was shorter in the EBAD group (225 vs. 173.5min, P < 0.001). Regarding incomplete small bowel obstruction, a higher prevalence was observed in the DS group compared to the EBAD group (7.2% vs 2.5%, P = 0.301). 7 patients (11.3%) in the DS group developed a para-stomal hernia, while no patient suffered a catheter-related complication. The median postoperative hospital stay was shorter in the DS groups than in the EBAD group (7 vs 8days, P = 0.009). The median residence time of endo-luminal balloon-assisted drainage was 5.41days. The median average and total volume of drainage were 51.57ml/day and 255ml, respectively. EBAD is feasible and safe with similar postoperative complications when compared with a DS. EBAD may replace DS after rectum resection.

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial

BackgroundThe aim of the present study is to present the three years follow-up a randomised controlled trial that compared Hartmann's Procedure (HP) with sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) (PA) in a randomised design to determine the optimal treatment strategy for perforated diverticulitis with purulent or fecal peritonitis. MethodsData were prospectively gathered for the first 12 months after randomization and retrospectively collected up to 36 months. The primary long-term endpoint was stoma free rate 36 months after the index procedure. Secondary outcomes were patients with a stoma at 36 months, percentage of stoma reversals, related reinterventions, parastomal/incisional hernia rates, total in hospital days including all readmissions regardless their relation to the intervention, overall morbidity and mortality. ResultsThree years follow-up was completed in 119 of the originally 130 included patients, with 57 (48%) in the PA-group and 62 (52%) patients in the HP-group. 36 months stoma free rate was significantly better for patients undergoing PA compared with HP (PA 92% vs HP 81%, hazard ratio 2.326 [95% CI 1.538–3.517]; log-rank p < 0·0001). Stoma reversal rates did not significantly differ (PA 31/40(78%) versus HP 45/61(74%), p = 0.814). Overall cumulative morbidity (PA 21/57(36%) versus HP 30/62(48%), p = 0.266) and mortality (PA 6/57(11%) versus HP 7/62 (11%), p = 1.000) did not differ between groups. However, more parastomal hernias occurred in the HP-group (HP 10/62(16%) vs PA 1/57(2%), p = 0.009) and the mean total in hospital days after three years follow-up was significantly lower in the PA-group compared to the HP-group (PA 14 days (IQR 9.5–22.5) versus HP 17 days (IQR 12.5–27.5)), p = 0.025). ConclusionLong-term results showed that in haemodynamically stable, immunocompetent patients primary anastomosis is superior to Hartmann's procedure as treatment for perforated diverticulitis with respect to long-term stoma free rate, overall hospitalization and parastomal hernias.

Stoma creation is associated with a low incidence of midline incisional hernia after colorectal surgery: the "fighting over the fascia" theory concerning the incision and stoma hole.

Parastomal hernia (PH) develops more frequently than incisional hernia (IH) after colorectal surgery with stoma. This study evaluated our hypothesis that inward traction of the fascia when closing a midline incision widens the stoma hole and increases the incidence of PH. A total of 795 patients who underwent colorectal resection between 2006 and 2016 were retrospectively analyzed. The risk classification was constructed from IH risk factors extracted from the non-stoma group. Then, the classification was extrapolated to the stoma group for predicting midline IH and PH. The incidence of IH was 5.3% in the stoma group and 12.5% in the non-stoma group (p = 0.005). PH developed in 19.6% of 97 patients with permanent stoma. The risk classification was able to predict PH without a significant difference but was well balanced in patients with permanent stoma; however, it failed to predict IH in the stoma group. The risk classification constructed from the non-stoma group was useful for predicting not midline IH but PH, suggesting that the stoma site was the most vulnerable for herniation. The "fighting over the fascia" theory between the midline incision and stoma hole may explain the causal relationship between the midline IH and PH.

Parastomal hernia repair

Despite significant advances in abdominal wall reconstruction, parastomal hernias remain a complex problem, with a high risk of recurrence following repair. While a number of surgical hernia repair techniques have been proposed, there is no consensus on optimal management. Several clinical variables must be considered when developing a comprehensive repair plan that minimizes the likelihood of hernia recurrence and surgical site occurrences. In this review, we describe the incidence of parastomal hernias and discuss pertinent risk factors, medical history findings, physical examination findings, supplementary diagnostic modalities, parastomal hernia classification systems, surgical indications, and repair techniques. Special consideration is given to the discussion of mesh reinforcement, including available biomaterials, anatomic plane selection, and the extent of mesh reinforcement. Although open repairs are the primary focus of this article, minimally invasive laparoscopic and robotic approaches are also briefly described. It is our hope that the provided surgical outcome data will help guide surgical management and optimize outcomes for affected patients.

Does Early Upper Tract Diversion and Delayed Undiversion in Megaureters Secondary to Severe Posterior Urethral Valves Lead to Better Renal Outcomes?

Background:There are conflicting reports for the management of severe posterior urethral valve (PUV) after ablation. The primary objective was to assess the renal outcomes using the estimated glomerular filtration rate (eGFR) and secondary outcomes in severe PUVs who underwent early partially diverting reduction ureterostomy (PDRU) and a delayed undiversion protocol.Materials and Methods:This 10-year retrospective study reviewed the records of 1094 boys with PUV, where severe PUV cases were treated with early PDRU (324 surgeries). We then analyzed those patients who completed the early diversion and delayed undiversion protocol. The long-term renal outcomes using eGFR and antero-posterior diameter (APD) were compared at various time points using appropriate statistical methods.Results:Of the 171 severe PUV patients who underwent PDRU, 31 completed undiversion and 26 (47 renal units) were analyzed after exclusions. The mean age (standard deviation) at presentation was 1.46 ± 4.1 months. Thirty-two units were refluxing and 15 were nonrefluxing megaureters. PDRU was closed at a mean age of 3.9 years and had a mean duration of follow-up of 6.4 years. The mean eGFR increased from a minimum of 10.78 ± 10.25 at baseline and remained stable at 28.69 ± 18.89 after closure of both stoma. Similarly, mean APD decreased from 12.07 ± 6.79 at the diagnosis to 7.00 ± 6.20. Three patients (3 renal units) required revision of the stoma for stenosis and 1 patient had a parastomal hernia that was repaired at the time of undiversion.Conclusions:In severe PUVs, early PDRU with delayed undiversion is a reliable surgical option that may ensure better renal outcomes in the long-term. Nonrefluxing renal units recover better than the refluxing. APD measurements also are shown to improve favorably.

A Case of Parastomal Hernia Treated by Laparoscopic Sugarbaker Technique

A Case of Parastomal Hernia Treated by Laparoscopic Sugarbaker Technique

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair.

In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available. The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS. Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n=11) and with a ready-made specific mesh (SM, n=22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant. We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P=.2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P=1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation. In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

Application of totally visceral sac separation in abdominal wall hernia

To investigate the application of totally visceral sac separation (TVS) in the treatment of ventral hernia, to summarize the operation procedure and to analyze its safety and effectiveness. Twenty-one consecutive primary and secondary ventral hernias cases were repaired using the TVS procedure from December 2019 to December 2020. A large mesh should be placed in retrorectus sublay or underlay preperitoneal using the minimally invasive procedure. The indications for this procedure include umbilical, incisional hernia, linea alba hernia, lumbar hernia, and parastomal hernia. All the operations were successful, of which 2 cases were converted to laparotomy because of the failure of anterior peritoneal cavity construction and the difficulty of anterior defect closure. The mean operation time was 140 mins (70-260 min), postoperative pain was mild, and the mean visual analogue scale(VAS) was 2.5 (1-4) on the first postoperative day. There were no recurrent cases during the follow-up for more than 6 months. TVS procedure is safe and highly reproducible. Without expensive anti-adhesion mesh and fixation tacker, the technology of TVS is a good technique for the surgical treatment of ventral hernia.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Risk factors and natural history of parastomal hernia after radical cystectomy and ileal conduit.

To investigate the incidence, risk factors and natural history of parastomal hernia (PSH). We reviewed the records of patients who underwent radical cystectomy (RC) and ileal conduit (IC) procedure between 2007 and 2020. Patients who had available follow-up computed tomography (CT) imaging were included in this study. All CT scans were re-reviewed for detection of PSH according to Moreno-Matias classification. Patients who developed hernia were followed up and classified into stable or progressive (defined as radiological upgrading and/or need for surgical intervention) groups. Multivariable Cox regression was performed to identify independent predictors of hernia development and progression. A total of 361 patients were included in this study. The incidence of radiological PSH was 30%, graded as I (56.5%), II (12%) and III (31.5%). The median (interquartile range [IQR]) time to radiological hernia was 8 (5-15) months. During the median (IQR) follow-up of 27 (13-47) months in 108 patients with a hernia, 26% patients progressed. The median (IQR) time to progression was 12 (6-21) months. On multivariable analysis, female gender (hazard ratio [HR] 1.86), diabetes (HR 1.81), chronic obstructive pulmonary disease (COPD; HR 1.78) and higher body mass index (BMI; HR 1.07 for each unit) were independent predictors for radiological PSH development. No significant factor was found to be associated with hernia progression. Radiological PSH after RC and IC occurred in 30% of patients, a quarter of whom progressed in a median time of 12 months. Female gender, diabetes, COPD and high BMI were independent predictors for radiological hernia development.

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a randomised controlled trial

BackgroundParastomal hernia is a common complication of an enterostomy and can have a significant impact on health-related quality of life. Currently used methods of repair have high recurrence rates and considerable risk for complications. We have developed a new technique for parastomal hernia repair that uses full-thickness skin graft as reinforcement.MethodsThis study protocol describes a multicentre randomised controlled trial on parastomal hernia repair comparing a new full-thickness skin graft technique with conventional synthetic composite mesh as reinforcement of the abdominal wall. Patients with a symptomatic parastomal hernia will be included and followed up at 3, 12 and 36 months, with surgical complication as the primary outcome. Secondary outcomes will be recurrence rate and health-related quality of life assessed with VHPQ, EORTC C30 and CR29. Tissue biology and collagen metabolism will be investigated pre- and postoperatively using biopsies of the abdominal wall fascia and blood samples.DiscussionParastomal hernia constitutes a major clinical problem where the prospects of a good result after hernia repair are presently poor. This new method of repair with full-thickness skin grafting could be a new alternative in our surgical toolbox, but before then, it must be evaluated properly.Trial registrationClinicalTrials.gov NCT03667287. Registered on September 12, 2018