Peristomal Hernia Underlay Technique
David E. Beck
INDICATIONS/CONTRAINDICATIONS
Peristomal hernia is one of the more common late complications of an ostomy. Indications for repair include bowel obstruction, incarceration, or enlargement of the hernia to the point where it interferes with appliance wear or the hernia is unsightly. The repair can be performed with open or laparoscopic techniques. Laparoscopic repair is suitable when the patient’s stoma is appropriately sited, the patient lacks a history of extensive adhesions, and the hernia is not too large. Excessive large peristomal hernias are often more appropriately repaired with an open technique. Obtaining good results with underlay mesh usually requires a mesh with at least a 3-5 cm overlap of the mesh beyond the edges of the hernia. This is difficult to accomplish laparoscopically with large hernias. Another relative contraindication is the need for an associated open procedure. Repair of both paraileostomy and paracolostomy hernias is suitable for laparoscopic procedures and several techniques of repair have been described. This chapter discusses several methods of underlay mesh repair including a “keyhole” technique, a method similar to that described by Sugarbaker in 1980, and a combination of both that has been referred to as a sandwich technique.
PREOPERATIVE PLANNING
Preoperative Preparation
Standard bowel preparation is not mandatory. However, because the empty colon handles better than the stool-filled colon, it is the author’s preference to have patients, who can tolerate a preparation, ingest a limited isotonic lavage prep, such as one-fourth to one-half gallon of a polyethylene glycol solution. Patients are instructed to take only clear liquids the day before surgery. Oral antibiotics are prescribed in patients with colostomies and all patients receive standard intravenous broad-spectrum antibiotics within 1 hour of skin incision. Deep vein prophylaxis is also ordered. Informed consent for laparoscopic procedures should include the potential for conversion to an open procedure.
SURGERY
Patient Positioning and Preparation
After induction of general anesthesia, an orogastric tube and indwelling urinary bladder catheter are placed. If a laparoscopic procedure is planned, the patient is then placed in modified lithotomy position with the thighs even with the hips and pressure points appropriately padded. One or both arms may be tucked to facilitate securing the patients for the extremes of positioning used during laparoscopy. If only one arm is tucked, it should be on the side opposite the side of the hernia and stoma. The patient is then secured to the table with straps or tape placed across the chest just below the armpits. The skin is prepped with antiseptic solution and draping is done in a manner to provide for lateral exposure for ports, especially on the side opposite the hernia and stoma. One author has suggested covering the abdominal wall with an adhesive drape to limit potential contamination of the mesh.
Open Procedures
Exposure
The patient is usually explored from the midline, although in very large hernias an elliptical incision at or below the stoma may be used. Once the abdomen is entered, adhesions to the previous incisions
and those in the hernia sac are divided. The hernia sac is usually removed, but whether this is necessary remains unproved. From the midline, the stomal fascial defect is closed with permanent sutures (e.g., #2 polypropylene). Silva et al. (2014) prefer use of a quill suture.
and those in the hernia sac are divided. The hernia sac is usually removed, but whether this is necessary remains unproved. From the midline, the stomal fascial defect is closed with permanent sutures (e.g., #2 polypropylene). Silva et al. (2014) prefer use of a quill suture.
Fascial reinforcement in the underlay position can be accomplished with two techniques: keyhole or a Sugarbaker-type technique.
Mesh Placement
With a keyhole technique, a mesh size is selected that will extend 5 cm beyond the edge of the closed hernia. A cruciate hole, the size of the bowel, is created in the center of the mesh, and a slit is created from the medial side of the mesh to the central defect (Fig. 50-1). A critical part of this technique is to not make the keyhole too small so as to cause a bowel obstruction, but to not make it so large as to increase the risk of herniation. The cut mesh is then maneuvered around the bowel and sutured in place with polypropylene sutures. The slit is closed with sutures and sutures are placed at the corners and the middle edge of the mesh. Abdominal pressure holds the mesh against the abdominal wall during the healing process.
The Sugarbaker method requires that the bowel has adequate laxity to allow the bowel to track between the mesh and abdominal wall. If reduction of the hernia does not provide adequate laxity, additional mobilization of the bowel may be necessary to allow adequate lateralization of the bowel. The ostomy bowel is pulled intra-abdominally, to reduce any prolapse. The ostomy bowel is then pulled to the lateral or superior edge of the hernia defect. Some surgeons will then suture the ostomy bowel serosa to the peritoneum with absorbable sutures at the edge of the defect. The abdominal wall is also inspected for additional hernias that need repair. A piece of mesh that will cover the hernia defect with a 5-cm overlap is selected. Both synthetic and biologic meshes have been described. Synthetic mesh is less expensive and easier to fix to the fascia. The mesh is fixed at the edges, close to the bowel, and is medially sutured or tacked in position.
The sandwich is a combination of both the keyhole and Sugarbaker techniques, using a piece of mesh in the intraperitoneal position as in the keyhole technique and then lateralizing the bowel and covering this with another piece of mesh using the Sugarbaker technique. This technique does result in an area of mesh overlapping with mesh.
Laparoscopic Procedure
Instrument/Monitor Positioning
The primary surgeon will usually stand on the patient’s side opposite the stoma or between the patient’s legs (Fig. 50-2). The primary monitor is placed on the patient’s side that contains the stoma near the
level of the hip. A secondary monitor can be placed at the patient’s shoulder or at an alternate site viewable by the assistant or surgical technician. Insufflation tubing, suction tubing, cautery power cord, laparoscopy camera wiring, and a laparoscope light cord are brought off the patient’s side. A 10-mm laparoscope with a 30-degree lens is preferred.
level of the hip. A secondary monitor can be placed at the patient’s shoulder or at an alternate site viewable by the assistant or surgical technician. Insufflation tubing, suction tubing, cautery power cord, laparoscopy camera wiring, and a laparoscope light cord are brought off the patient’s side. A 10-mm laparoscope with a 30-degree lens is preferred.
