Approaches for Parastomal Hernia Formation During Laparoscopic Creation of Permanent End Stomas: Rationale, Techniques, and Outcomes

Author (year)

Type of study

Sample size

TPS/EPS

Primary surgery

Median follow-up (months)

Outcomes

(TPS vs. EPS)

Hamada et al. (2012) [32]

Retrospective

APR

33.3 vs. 4.5% (p = 0.031)

Leroy et al. (2012) [31]

Retrospective

APR

N/A

33.3 vs. 0% (p = 0.02)

Funahashi et al. (2014) [55]

Retrospective

APR/TPE

34.8 vs. 17.6% (p < 0.01)

Heiying et al. (2014) [29]

Randomized trial

APR

11.1 vs. 0% (p = 0.15)

Hino et al. (2017) [56]

Retrospective

APR/

Hartmann’s

41 vs. 13% (p = 0.02)

EPS extraperitoneal stoma, TPC transperitoneal stoma, APR abdominoperineal resection, TPE total pelvic exenteration

Prophylactic Mesh Use

Select reports have supported the routine use of prophylactic mesh based on the available published literature [33]. Ultimately, prophylactic mesh placement has been shown to have a low complication profile in long-term follow-up studies [34], suggesting the procedure to be safe in these clean-contaminated procedures. The use of prophylactic mesh should thus be left to the surgeon’s judgment; however, patients with elevated BMI, diabetes, or undergoing surgery for malignancy may be at an increased risk, further supporting the use of prophylactic mesh [35].

Contraindications would mainly include those patients with diffuse fecal or purulent contamination for concern of mesh infection. These include situations where significant contamination has occurred during an emergent procedure or due to visceral injury, as well as patients with peritoneal carcinomatosis or short-life expectancy.

Preoperative Planning, Patient Workup, and Optimization

In the setting of elective procedures, it is important to ensure that modifiable patient factors have been optimized in preparation for surgery. Preoperative planning is the same whether the surgeon is planning an extraperitoneal approach or the use of prophylactic mesh. Most patients who will require a permanent stoma will require surgery on a semi-urgent or urgent basis for indications such as inflammatory bowel disease or malignancy. As such, there is often an insufficient amount of time to optimize many modifiable factors including smoking status, obesity, and nutritional status among others. Various pre-habilitative programs have been proposed to prepare patients for abdominal surgical procedures but none in particular to optimize the outcomes related to the creation of a permanent end stoma. Abdominal imaging with computed tomography (CT) will often have been performed for disease-specific purposes. This imaging can be used to visualize abdominal wall anatomy and the intactness of the various muscular and fascial layers, which can be particularly important in patients with previous abdominal surgical procedures.

Although preoperative bowel preparations and intravenous antibiotics have been shown to decrease the likelihood of a surgical site infection, there has not been any correlation with a decreased risk of infectious peristomal complications. Bowel preparation can help mitigate intra-abdominal contamination during laparoscopy although some surgeons believe that the liquidity of intracolonic contents can make spillage more likely with an intraoperative colonic injury.

Preoperative assessment of the patient’s abdominal wall is crucial to identify the optimal site for stoma creation. This is usually performed by a trained enterostomal therapy (ET) nurse. Various factors are taken into account including naturally occurring skin creases in the seated and supine positions, surgical scars, the patient’s belt line, the width of the rectus muscles, the type of stoma being created, the patient’s abdominal wall adiposity, as well as factors such as manual dexterity, location of a seatbelt, and others. It is important to protect the skin marking, often by marking the skin and placing a watertight adhesive on top to prevent the marking from being washed off. Furthermore, informing your ET nurse of the potential location of incisions for the laparoscopic procedure may allow for proposed stoma sites to be incorporated into incisions. Additionally, in complex cases, selection of bilateral or four-quadrant stoma locations can also provide the surgeon with more options at the time of stoma creation, especially with obese abdominal walls and difficulty bring through the intestinal segment. For additional details on optimizing stoma function, please refer to Chap. 36 on best practices in planned and unplanned stoma creation.

Operative Setup

Procedures can be performed using a laparoscopic approach. Ensuring the drapes are sufficiently laterally positioned is important to allow for exposure of the skin for the lateral fixation sutures. Placing the lateral drapes just medial to the anterior axillary line will allow for sufficient lateral access.

Extraperitoneal Stoma Creation

Principles and Quality Benchmarks

A number of techniques are available to allow for the creation of an extraperitoneal tract. When performed laparoscopically, the maneuver tends to be technically challenging. The challenge lies in the ability to create the intraperitoneal opening as well as the supraperitoneal tunnel under visualization while maintaining pneumoperitoneum. In the view of the authors, this approach has little role during the creation of temporary stomas. The decision that needs to be made is the position of the stoma relative to the various abdominal wall layers. One of the more common approaches is to bring the colostomy anterior to the parietal peritoneum, below all the abdominal wall structures [31, 32, 36] (Fig. 37.1) or, less commonly, below the transversalis muscle but anterior to the transversalis fascia and parietal peritoneum [37]. Furthermore, a dissector is needed to create the extraperitoneal tunnel from the peritoneum at the level of the skin aperture to the window created intraperitoneally. Some surgeons have used the curve of a Kelly clamp to gently separate the appropriate layers. Leroy and colleagues discuss the EndoH® retractor (Karl Storz® (Tuttlingen, Germany) [31], whereas others have used the Covidien® Endo Retract™ Maxi 10 mm device (Mansfield, MA, USA) [36].

../images/465809_1_En_37_Chapter/465809_1_En_37_Fig1_HTML.jpg — Fig. 37.1

Cross-sectional image of the abdominal wall delineating a retrorectus extraperitoneal tract for a permanent stoma to prevent parastomal hernias

Operative Technique

Individual techniques vary, but consistently, the resectional aspect of the procedure is completed first, and the proximal transection margin is stapled off. In abdominoperineal resections (APR) , if the perineal dissection is being performed supine, the specimen is often removed through the perineum and the perineal wound closed prior to reinsufflation. If the perineal is approach prone, the colostomy is fashioned first.

During this approach, it is important to mobilize the descending colon slightly more proximally to allow for sufficient mobility of the colonic conduit that is to be brought through the extraperitoneal space. If an assistant port has been placed at the proposed stoma site, the port is removed, and a disc of skin is excised corresponding to the proposed stoma site. This aperture can vary between 20 and 25 mm depending on the width of the lumen and type of stoma being created. It is up to the surgeon to decide if the underlying subcutaneous fat is to be resected or separated. The anterior rectus sheath is identified and can be incised either in a cephalocaudal axis or in a cruciate fashion, after which the rectus muscle fibers are separated. It is important to ensure a perpendicular approach through the abdominal wall is being followed. The posterior rectus sheath, if present, is then identified and carefully incised to expose the intact peritoneum. The dissection of the extraperitoneal tract is often and more easily performed in an external to internal fashion. The width of the tract should be approximately 2 fingerbreadths or 5 cm and taken laterally to the paracolic gutter or smaller with end ileostomies. This is also performed with laparoscopic observation and guidance. The tunnel may often have to be angled in a slight cephalad fashion to accommodate the path along which the colon and mesocolon/mesentery must be brought along. Laparoscopically, the peritoneum is then incised laterally at the proposed entry site of the intestinal conduit of the end stoma. It is important to ensure that the size of the path being created accounts for the bulk of the mesentery/mesocolon . Leroy and colleagues report placing an absorbable suture loop around the distal end of the stoma that is then grasped by the laparoscopic grasper placed through the trephine opening [31]. The intestinal segment is gently pulled through, at times requiring digital assistance. The lateral parietal peritoneal opening may sometimes be narrowed down using intracorporeally placed absorbable sutures (3-0) to minimize the likelihood of a potential for herniation of intestinal content.

Tulina and colleagues rejuvenated the Goligher approach by creating the extraperitoneal tract along the retrorectus plane, anterior to the transversalis fascia and peritoneum [37]. They describe using the assistant trocar at the site of the stoma by gradually pulling it back from the intraperitoneal space to the appropriate abdominal wall level and then connecting the laparoscopic insufflation to assist with the separation of the planes using pneumodissection. The plane can be created during delivery of the bowel through the stoma aperture.

Pitfalls and Troubleshooting

In slim patients, the parietal peritoneum may be violated. In such situations, if the defect is too large, a different tract can be created, which when formally complete can then allow for the disrupted segment of peritoneum to be closed with laparoscopically placed sutures. Alternatively, the retrorectus plane described by Tulina and colleagues can be followed instead [37].

It is important to ensure the tract is sufficiently wide to allow for the intestinal segment and its mesentery to be passed through without tension or excessive narrowing. Lowering intra-abdominal pressures can decrease tension on the abdominal wall. The cut-edge of the mesentery or mesocolon should be kept in consideration as tension on this as the segment is being pulled through the tract may result in tears and bleeding. Bleeding can often be addressed with laparoscopic techniques but care must be taken not to affect the vascular inflow of the conduit. Conduits appearing ischemic at the time of stoma creation should be observed briefly in a non-insufflated state to ensure it is not a tension-related phenomenon; if there is no improvement in the appearance, adjuncts such as indocyanine green angiography can be used to objectively assess perfusion. Frankly ischemic stomas should be revised. Conversion to an open procedure should be based on the comfort of the surgeon to revise and manage these issues laparoscopically.

Caution should be taken in considering this for patients with Crohn’s disease. The mesenteric bulk and fistulizing nature of the disease as well as the frequent need for reoperations may result in intraperitoneal complications and abdominal wall inflammatory in case of recurrence.

Outcomes

A number of retrospective reports and two prospective randomized controlled trials have been reported, which are well summarized in a recently published meta-analysis comparing transperitoneal and extraperitoneal approaches for stoma creation [30]. In this review, the authors report lower rates of PSH (risk ratio 0.36; 95% CI 0.21–0.62; p < 0.001) and stoma prolapse (risk ratio 0.21; 95% CI 0.06–0.73; p < 0.01) with no difference in the rate of stoma necrosis. Well-designed randomized trials are pending at this time. No cost-effectiveness data are available. The published data on the comparative outcomes of extraperitoneal techniques in minimally invasive surgery are summarized in Table 37.1.

Prophylactic Mesh Placement

Principles and Quality Benchmarks for Prophylactic Mesh Placement for Permanent End Colostomies and Ileostomies

There are a number of approaches to the application of prophylactic mesh to decrease the likelihood of PSH and stoma prolapse with an end stoma. The main questions that should be asked are the following: (1) What type of mesh will be used? (2) Which technique and location of mesh placement will be employed?

As will be described in the outcomes section, the use of biologic mesh is not currently supported by the published data [38, 39]. Most of the published evidence describes outcomes following the placement of a retromuscular segment of nonabsorbable synthetic mesh in an open fashion. The focus of our discussion is on the laparoscopic placement, and as such, the main procedures would be a modified-Sugarbaker or a keyhole approach, both of which are the intraperitoneal techniques. Comparative trials of the keyhole and Sugarbaker techniques have focused on the therapeutic management of PSH. A number of trials have been published assessing these two approaches in the therapeutic treatment of PSH with no data available on their comparative efficacies in the prophylactic setting. These trials have noted improved results with the Sugarbaker approach, compared to keyhole approach , which has led surgeon to preferentially opt for the former approach [40, 41]. The senior author (SDW) performs the keyhole technique as it is his preferred method of therapeutic rather than prophylactic mesh placement, whereas the corresponding author prefers a Sugarbaker technique for the above reasons.

Most of trials included the use of lightweight macroporous polypropylene mesh, often with a single or dual composite component when used intraperitoneally. As reflected in the outcomes section (Table 37.2), most assessments of the efficacy of biologic mesh have failed to demonstrate any role in prophylaxis against PSH development. The jury is still out on the efficacy of heavy versus lightweight meshes although both authors prefer dual-layer composite lightweight macroporous mesh. The mesh is prepared externally and should be cut with the objective of a 10 cm overlap both medially and laterally.

Table 37.2

Review of large (>50 patients) randomized controlled studies of mesh prevention strategies for parastomal hernias

Author (year)	n	Mesh type	Mesh position	Technique	Outcome assessment	Follow-up	Outcome (no mesh vs. mesh)
Serra-Aracil et al. (2009) [57]	55	Synthetic, nonabsorbable	Sublay	Open	Clinical/CT	29 (median)	40.7 vs. 14.8 (p = 0.03)
Cui et al. (2009) [58]	60	Synthetic, nonabsorbable	Intraperitoneal	Open	Clinical/CT/ultrasound	36 (mean)	26.7 vs. 0% (p < 0.01)
Fleshman et al. (2014) [39]	113	Biologic	Intraperitoneal	Open	Clinical; CT if suspicion of PSH	24 (mean)	13.2 vs. 12.2% (p – NS)
Vierimaa et al. (2015) [59]	70	Synthetic, nonabsorbable	Intraperitoneal	Laparoscopic	Clinical/CT	12 (mean)	32.3 vs. 14.3% (p = 0.049)
Lambrecht et al. (2016) [60]	58	Synthetic, nonabsorbable	Sublay	Open	Clinical/CT	40 (median)	46 vs. 5% (p < 0.001)
Lopez-Cano et al. (2016) [61]	52	Synthetic, nonabsorbable	Intraperitoneal	Laparoscopic	Clinical/CT	26 (median)	64.3 vs. 25% (p = 0.005)
Brandsma et al. (2017) [43]	133	Synthetic, nonabsorbable	Sublay	Open	Clinical/CT	12 (median)	24.2 vs. 4.5% (p = 0.0011)
Odensten et al. (2019) [50]	211	Synthetic, nonabsorbable	Sublay	Open	Clinical/CT	12 (median)	30 vs. 29% (p = 0.866)