Open Parastomal Hernia Repair

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Dissection Planes

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  A robust knowledge of abdominal wall anatomy is critical to the success of PCS/TAR parastomal herniorrhaphy ( Fig. 7.1A ).

  

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  The linea semilunaris defines the lateral border of the rectus abdominis muscle. Innervation to the rectus is maintained by entering into the pre-transversalis/retromuscular plane medial to the linea semilunaris without dividing the intercostal branches entering the posterior aspect of the muscle belly. Subsequent lateral dissection can be accomplished posterior to the transversus abdominis muscle ( Fig. 7.1B ).

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  The mesh is placed within this broad retromuscular plane that extends under the costal margin superiorly, laterally to the psoas muscle, inferolaterally to the myopectineal orifice, and inferomedially to the retropubic space.

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  The relevant anatomy is discussed in greater detail in Chapter 1 .

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Comorbidities

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  Patient comorbidities must always be considered and optimized whenever possible. Comorbidities include diabetes mellitus, chronic obstructive pulmonary disease, cardiovascular disease, morbid obesity, cancer diagnoses, immunosuppression, ongoing infection (including mesh infections), presence of fistulas, and smoking.

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  PCS/TAR parastomal herniorrhaphy can be a prolonged operation because of adhesiolysis, stoma relocation, removal of previous mesh, and component separation. For patients who are poor operative candidates, the presence of comorbidities may be contraindications to this procedure.

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  We mandate smoking cessation in all patients before open repair and recommend weight loss in patients with a body mass index greater than 40 kg/m ² . Surgical weight loss procedures are performed if necessary to achieve this goal before parastomal hernia repair.

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  We routinely evaluate patients with preoperative computed tomography scans to fully characterize the extent, number, and location of the hernias. These studies are extremely helpful in preoperative planning ( Fig. 7.2 ).

  

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Two-Team Approach

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  Although not mandatory, a two-team approach can be beneficial because of the prolonged nature of this operation. One team focuses their efforts on adhesiolysis, intestinal mobilization, resection and repair of fistulas (if necessary), and stoma maturation at the conclusion of the procedure. The second team focuses on component separation and abdominal wall reconstruction.

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Operative Options

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  Multiple approaches to repair have been previously described. The myriad repair options stand testament to the difficulty of addressing the problem of parastomal hernia repair. Open, laparoscopic, mesh, and primary repairs all have been described with varying rates of recurrence.

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  We prefer an open repair with retrorectus dissection, transversus abdominis release, and mesh placement within the retromuscular plane. This repair is ideal because it addresses all three defects present in these patients: the parastomal defect, the commonly found ventral midline hernia, and the new defect created when relocating the ostomy.

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  This method also permits wide mesh overlap of the defect (regardless of its proximity to bony landmarks), recreates the peritoneal space (preventing interaction between the bowel and mesh), places the mesh in the preferred sublay space, and re-establishes the mechanical function of the abdominal wall by permitting primary defect closure and medialization of the rectus muscles.

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Mesh Selection

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  Synthetic, biologic, and bioabsorbable meshes have all been used for PCS/TAR parastomal repair. We use intermediate-weight, macroporous polypropylene mesh in most cases because of its low cost, ease of use, widespread availability, and effectiveness in clean and infected fields. Excellent data are available suggesting the use of polypropylene around an ostomy is both safe and efficacious.

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