Parastomal hernia

parastomal hernia repair
guidelines 2020
classification

1. Guidelines on prevention and treatment of parastomal hernia Georges KHALIFEH , FFI GHPSO C hirurgie digestive et viscérale

2. “Some degree of herniation around a colostomy is so common that this complication may be regarded as inevitable ” Goligher

3. What is the incidence of parastomal hernias ? Is there a difference in the incidence of parastomal hernia for colostomy, ileostomy or ileal conduit?

4. INCIDENCE Estimation de l’incidence globale de la hernie parastomiale : 30 % à 12 mois 40 % à 2 ans 50 % lors d’un suivi supérieur La colostomie terminale est associée à une incidence plus élevée de hernie parastomiale , en comparaison à la colostomie latérale ou à l’ iléostomie latérale.

5. Parastomal Hernia Risks Factors Patient factors Age Intra-abdominal pressure factors Obesity Emphysema Wound healing factors Infection Steroids Genetics ( collagen deficiency ) Surgical Technique Site outside of rectus sheath Stoma defect created too large

6. Symptoms of parastomal hernia Protrusion of stoma beyond abdominal wall Prolapse of stoma Enlargement of stoma Appliance leakage / poor fit Pain Incarceration or strangulation

7. Classification

8. DEVLIN : Subcutaneous Interstitial Perstomal intrastomal

9. Classification radiologique

10. EHS Classification

11. What is the diagnostic accuracy of the clinical diagnosis of parastomal hernias versus a diagnosis by medical imaging ? Physical examination – on lying down and standing with valsalva Digital examination enables the fascial aperture and par astomal tissues to be assessed Imaging

12. Are there techniques for stoma creation that result in fewer parastomal hernias ? Extraperitoneal versus transperitoneal stoma construction Stoma construction at a lateral pararectus location versus a transrectus location Size of the fascial aperture No recommendation can be made in preference of stoma construction through the extraperitoneal over the transperitoneal route. No recommendation can be made in preference of stoma construction at a lateral pararectus location over a transrectus location. We suggest keeping the size of the fascial aperture as small as possible to allow passage of the intestine through the abdominal wall without causing ischemia.

13. Does the use of a prophylactic mesh during stoma construction reduce the incidence of parastomal hernias?

14. Anterior fascial fixation? YES OR NO

15. Indications for hernia repair Surgical repair is indicated for patients who develop acute parastomal hernia complications and for those with chronic symptoms that impair the quality of life .

16. Acute complications  — There is a low rate of life-threatening complications associated with parastomal hernia . Urgent or emergent surgical repair is necessary for patients with a bowel obstruction resulting from an i ncarcerated hernia because of the risk for strangulation and bowel ischemia

17. Chronic bothersome symptoms Patients with chronic symptoms that impair the quality of life are listed below, and patients may benefit from elective hernia repair . ●Stoma appliance dysfunction and leakage not responsive to conservative measures. ● Peristomal skin breakdown related to shear injury or ischemia from pressure on the thinned peristomal skin. ●Recurrent partial bowel obstruction. ●Chronic abdominal pain related to the parastomal hernia .

18. Management Conservative Surgery Closure of stoma Direct fascial repair Relocation Mesh repair

19. Is there a place for watchful waiting in patients with a parastomal hernia ?

20. Direct fascial repair Reduce size of hernia defect by reapproximating the fascial edges of trephine with sutures Advantage : simple technique avoids laparotomy low complication rate in elective operation may have a role when there is a strong desire to avoid mesh or more major surgery Disadvantage : excessive tension and subsequent failure in large fascial defect high recurrence rate – reported in various literature to be 46 100%

21. Is a suture repair for elective parastomal hernia repair an option? It is recommended not to perform a suture repair for elective parastomal hernia surgery because of a high risk of recurrence, T his approach should be reserved for patients with co-morbidities, short life expectancy or with a contra-indication for suture repair with prosthetic reinforcement (emergency surgery, strangulation with ischemic compromise , cirrhotic patients with ascites. . .).

22. Stoma r elocation Advantage: useful if the current stoma position unsatisfactory can be done with or without laparotomy lower recurrence rate than direct fascial repair Disadvantage: local recurrence rate reported in literature ~36.3% (range up to 76.2 %) not feasible if patient has multiple previous scars risk of incisional hernia at the site of the original stoma or midline wound more risk of morbidity if require laparotomy

23. Relocation + mesh

24. P rosthesis after stoma relocation. Some authors propose placement of prosthesis covering the two sites, the stoma and the midline incision , to prevent recurrent abdominal wall hernia

25. S toma relocation This approach avoided because the new stoma at new site is associated with the same high risk of hernia formation

26. Mesh repair Overall recurrence rates after mesh repair vary between 7-17% (depending on technique and placement of mesh ) Overall mesh infection rate 2.4 % Risk of mesh infection did not differ between mesh techniques

27. Onlay technique First described by Rosin and Bonardi in 1977 Mesh placed subcutaneously and fixed onto the anterior rectus aponeurosis Prefascial plane was entered through a lateral parastomal incision After reduction of hernia sac, the fascial opening was narrowed with sutures and mesh was placed to reinforce the suture repair

28. Onlay technique Advantage: more straight forward surgical technique involving a mesh avoids intra-abdominal dissection Disadvantage: higher risk of contamination & sepsis than sublay technique extensive dissection of subcutaneous tissue predisposes to hematoma / seroma formation risk for ischemic injury to skin => impair wound healing Intra-abdominal pressure may lead to detachment of mesh resulting in recurrence

29. Onlay

30. Sublay technique Mesh placed between rectus muscle and posterior sheath Fewer studies evaluating this method of mesh placement Small series with relatively short follow up (most <12mo ) Overall recurrence rate 6.9 %

31. Sublay technique Advantage intraabdominal pressure does not dislocate the mesh from repairno direct contact with bowel Disadvantage more technically challenging than onlay technique

32. Inlay tecnique Mesh cut to size of abdominal wall defect, placed within fascial defect and sutured to fascial edges Abandoned because of high failure rates

33. Intraperitoneal onlay position (IPOM) Mesh placed intraabdominally on the peritoneum 2 techniques Sugarbaker technique Keyhole technique

34. Sugarbaker technique Sugarbaker first described his technique in 1980 intraperitoneally placed mesh via a laparotomy and sutured to fascial edge bowel is lateralized overlap of mesh and adjacent fascia Advantage: generous mesh overlap flap valve effect created able to withstand increased intraabdominal pressure

35. Sugarbaker technique Disadvantage : mesh related complications dense adhesions causing intestinal obstruction requiring laparotomy bowel erosion & fistula formation Main application of these techniques is in laparoscopic repair

36. Technique de cuilleret

37. Modified sandwich

38. The following recurrence rates were noted: Primary suture repair – 69.4 percent Onlay mesh – 17.2 percent Sublay mesh – 6.9 percent Open , intraperitoneal mesh Sugarbaker – 15 percent Keyhole – 7.2 percent Laparoscopic mesh • Sugarbaker - 11.6 percent •Keyhole – 11.6 percent •Sandwich – 2.1 percent

39. Laparoscopic techniques Conversion rate 3.6 % Mesh infection rate 2.7 % Wound infection 3.3 % bowel injury 4.1%

40. For patients with appropriate indications for repair who have small defects (<5 inches ), and no expectation of significant intra-abdominal adhesions, we suggest a laparoscopic approach rather than open repair

41. Laparoscopic \laparotomy When feasible, laparoscopic ostomy formation is preferred to ostomy formation via laparotomy. Grade of Recommendation : Strong recommendation based on low-quality evidence , 1C .

42. Loop ileostomy \ transverse loop Loop ileostomy is preferred over transverse loop colostomy for temporary fecal diversion in most cases. Grade of Recommendation: Weak recommendation based on moderate-quality evidence , 2B.

43. Prophylactic mesh ? Lightweight polypropylene mesh may be placed at the time of permanent ostomy creation to decrease parastomal hernia rates. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B

44. Extraperitoneal tunneling of end colostomies? Extraperitoneal tunneling of end colostomies may decrease parastomal hernia rates. Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C.

45. stomy -site skin closure? S tomy -site skin reapproximation should be performed when feasible, and pursestring skin closure may have advantages compared with other techniques. Grade of Recommendation : Strong recommendation based on moderate-quality evidence , 1B.

46. Parastomal hernia repair ! Parastomal hernia repair should typically be performed by using mesh reinforcement or by relocating the stoma. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

47. Prosthetic mesh increase infection, erosion ? Prosthetic mesh may be used during parastomal hernia repair with low short-term risk of intestinal erosion or mesh infection. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

48. Collagen based bioprosthetic grafts ? Bioprosthetic material may be used as an alternative to synthetic mesh for repair of parastomal hernias. Grade of Recommendation : Weak recommendation based on low quality evidence , 2C.

49. Laparoscopic parastomal hernia repair Laparoscopic parastomal hernia repair with mesh may be a safe alternative to open mesh repair. Grade of Recommendation : Strong recommendation based on low-quality evidence , 1C.

50. There are some intra and post-operative measures that can help  to prevent  the development of parastomal hernias, such as: Correct positioning, placing the orifice through the rectus muscle Avoiding excessive opening of the fascia (as small as possible, as long as it doesn’t compromise stoma perfusion) Wearing a support garment (belt or underwear) Avoiding heavy lifting and straining Avoiding being overweight and maintaining a normal body mass index when possible

51. Thank you