Robotic parastomal hernia repair

Introduction

Parastomal hernia is one of the most common complications following ostomy creation and may be unavoidable considering the mechanics of the abdominal wall and the need to keep a functioning loop of intestine coming through the dynamic abdominal wall. Parastomal hernias occur in almost half of ostomies created, depending on the type of ostomy. In 2003, the prevalence of ostomies was estimated to be 800,000, and this number has likely risen, considering that 120,000 new ostomies are predicted to be created yearly, patients are continuing to live longer, and the incidence of obesity is rising.

A multitude of risk factors that increase the development of parastomal hernias have been identified, including advanced age, diabetes, obesity, wound infection, malnutrition, steroid use, immunosuppressant medications, inflammatory bowel disease, malignancy, and emergent surgery. Obesity, which in one study was defined as a body mass index >30 kg/m ² or a waist circumference greater than 39 inches, was also found to be a strong independent risk factor for parastomal hernia development after a permanent colostomy.

Parastomal hernias can cause significant complications for patients and include bowel obstruction, physical discomfort, interference with daily life, and need for additional surgery. ^, When comparing patients with parastomal hernias to those without, there is a reported significantly lower quality of life due to a decrease in physical functioning and general health as well as a reported increase in pain. Prevention and repair of these hernias is difficult and currently no standard of care exists.

According to data from the Americas Hernia Society Quality Collaborative, almost 80% of parastomal hernia repairs are performed using an open approach. This parallels the overall ventral hernia repair literature. Despite good results with minimally invasive approaches, the adaptation of minimally invasive techniques remains low nationally. The most recent review of the literature indicates that minimally invasive parastomal hernia repair is an effective treatment for parastomal hernia based on low mortality, low morbidity, reduced length of stay, shorter operative time, and fewer postoperative complications. ^, In addition, these results are significantly better than those of open repairs. ^,

Decision-making regarding when to operate on a parastomal hernia is complex. Emergent indications include acute bowel obstructions resulting from strangulation and concerning for possible bowel perforation. Elective repairs are more common and require a careful consideration of patient comorbidities, preoperative optimization, and possible techniques ( Figs 16.1–16.3 ).

Indications for possible repair

• I.

  Parastomal bulge present with concomitant abdominal distention or pain

• II.

  Parastomal hernia resulting in enteric leakage, ulceration, or difficulty with application of ostomy appliance

• III.

  Incarceration

• IV.

  The hernia affects the patient’s appearance or activities of daily living

Possible contraindications for repair

• I.

  Malignant recurrence

• II.

  Inability to tolerate general anesthesia

Principles of parastomal hernia repair

Parastomal hernia repair (PHR) is a challenging operation with high rates of complications and recurrence. In addition, there is no consensus for one methodology over the other, even in expert hands. Recent recommendations by Shah et al. for proper hernia repair include reduction of hernia contents, excision of hernia sac and attenuated tissue, re-approximation of healthy fascia, and reinforcement with mesh. In the past, PHRs have resulted in recurrence rates of up to 76% with open surgery and up to 28% with the laparoscopic technique. The ability to perform a fascial defect re-approximation and place a large mesh using minimally invasive techniques may improve wound events compared to open repairs.

In 1985, Paul H. Sugarbaker originally described a technique for PHR using the previous midline laparotomy incision and fixating the ostomy laterally by placing a piece of mesh over the bowel and fixating the mesh to the abdominal wall. As the use of laparoscopic techniques expanded to include ventral hernia repairs, Leblanc et al. described the laparoscopic PHR as a possible solution to a complex repair.

Three types of laparoscopic repairs have been described: the modified Sugarbaker, the keyhole, and a combination of both (the sandwich technique). The Sugarbaker technique is described as placing a flat piece of mesh underneath the ostomy and securing the intra-abdominal portion of the bowel out laterally ( Figs 16.12 and 16.13 ). The keyhole technique describes circumferentially covering the ostomy with a piece of mesh without lateralization. These were initially performed with the mesh being intra-abdominal. This has been advanced by placing the mesh retroperitoneally and in the retrorectus space to keep the mesh extraperitoneal. Pauli described his technique of performing an open PHR by doing a retromuscular dissection, posterior component separation via a transverse abdominis release, and a modified Sugarbaker-style mesh placement in the retromuscular space. In 2012, a systematic review of the literature found no advantage of laparoscopic over open repair with respect to morbidity or mortality. The most recent review of the literature for laparoscopic PHR reported an overall recurrence rate of 17.4%, with the modified laparoscopic Sugarbaker approach having a 10.2% recurrence, while the keyhole approach recurrence rate approached 28%.

Minimally invasive versus open surgery

Many factors contribute to decision-making regarding PHR using minimally invasive versus open techniques. Contraindications to minimally invasive repairs are similar to those for ventral hernia repairs and are related to patient ability to tolerate pneumoperitoneum, surgeon skill, and availability of instrumentation. Other considerations include patients who have undergone many open procedures or have inflammatory processes that may increase the risk of enterotomy or bleeding.