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Technique of parastomal hernia repair using synthetic mesh
SURGEON’S WORKSHOP
TECHNIQUE OF PARASTOMAL HERNIA REPAIR USING SYNTHETIC MESH MICHAEL E. FRANKS
AND
RONALD L. HREBINKO, JR
ABSTRACT We describe a reliable and simple technique of parastomal hernia repair using primary fascial repair with synthetic mesh that minimizes the known complications of infection and stomal stenosis while eliminating the need for peritoneal exploration, lysis of adhesions, and relocation of the stoma. We applied this technique to 6 patients (aged 65 to 83 years) with symptomatic, first-time parastomal hernias. The results are discussed. UROLOGY 57: 551–553, 2001. © 2001, Elsevier Science Inc.
P
arastomal hernia (PSH) after ileal loop diversion is a common occurrence, with a reported incidence of 2% to 6.5%.1–3 The urologic and general surgical literature contain surprisingly little information on the technique of PSH repair. Hopkins and Trento3 in 1982 were the first to use an in situ or local repair and synthetic mesh for PSH after ileal loop diversion. Their case report involved extensive intraperitoneal dissection and mobilization, with postoperative dermatitis and abscess formation. We describe a straightforward alternative method of local fascia repair with synthetic mesh onlay for patients with first-time PSH. MATERIAL AND METHODS Before surgery, a loopogram, intravenous urogram, and computed tomography (CT) scan are carried out. These procedures define concomitant abnormalities that may be repaired at the time of herniorrhaphy such as upper tract transitional cancer, obstruction, or stomal stenosis. The urine is cultured 7 to 10 days before surgery, either from a fresh stoma bag or (preferably) from sterile loop catheterization. Oral antibiotic agents are started 5 days preoperatively based on the reported sensitivities. Broad-spectrum intravenous antibiotic agents are given before the skin incision and continued for 24 to 48 hours postoperatively. At the time of surgery, the stoma appliance is removed and the stoma is prepped into the operative field. An 8 to 10-cm incision is made inferior and lateral to the skin mark made by the patient’s stoma wafer (Fig. 1). Dissection proceeds around the subcutaneous portion of the ileal loop. The hernia sac, From the Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Reprint requests: Ronald L. Hrebinko, Jr., M.D., 5200 Centre Avenue, Medical Center Building, Suite 209, Pittsburgh, PA 15232 Submitted: July 28, 2000, accepted (with revisions): October 16, 2000 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. Incision lateral to stoma and parastomal hernia. 0090-4295/01/$20.00 PII S0090-4295(00)01014-1 551
FIGURE 2. Hernia sac exposed deep to Scarpa’s fascia.
FIGURE 4. Synthetic mesh tailored.
FIGURE 3. Primary fascial closure after reduction of hernia sac.
which is usually lateral to the loop because of the mesenteric location, is identified, cleaned, and reduced or excised (Fig. 2). The fascial defect is further defined using sharp dissection and reapproximated prior to mesh onlay, if possible, using 2-0 interrupted, monofilament sutures (Fig. 3). If there is too much tension to reapproximate the fascial edges, we proceed with mesh onlay without fascial closure. A piece of nonabsorbable synthetic mesh (Marlex; CR Bard, Billerica, Mass) is soaked in povidine solution, cut carefully in a keyhole configuration (Fig. 4), and positioned to fit around the loop, its mesentery, and the fascial defect. Care is taken to 552
FIGURE 5. Mesh sutured in place to reinforce repair.
avoid constriction of the bowel and its mesenteric blood supply. Nonabsorbable monofilament 2-0 sutures are used to tack the mesh to the underlying fascia (Fig. 5). A closed drain is placed superficial to the mesh, the wound is closed in two layers, and the stoma appliance is replaced. UROLOGY 57 (3), 2001
RESULTS We used this technique on 6 patients, aged 65 to 83 years. Length of hospitalization was 2.5 days (range 2 to 5). At a mean follow-up of 26 months (range 2 to 42), there were no recurrences on follow-up examination or by CT scan, no mesh infections, and no stoma or loop stenoses. COMMENT Technical details of repair of PSH are often absent from surgical atlases, texts, or journal articles. Most articles are found in the general surgery literature and describe repair of PSH associated with enteral stomas, rather than urinary stomas. Rubin et al.4 have evaluated the techniques of primary repair, stoma relocation, or primary repair using synthetic mesh, and found that recurrence was common after all procedures, but more likely after primary repair alone (76% recurrence at 31 months). Importantly, stoma relocation was associated with a complication rate of up to 88%. Our
UROLOGY 57 (3), 2001
method, which uses an extrafascial approach, avoids the multiple incisions and associated morbidity associated with stomal relocation or intraperitoneal in situ repairs. CONCLUSIONS We describe a simple technique of PSH repair that can be completed in 2 to 3 hours. There were no postoperative stomal stenoses or recurrent hernias and, with careful attention to preoperative cultures, no infections. REFERENCES 1. Schmidt JD, Hawtrey CE, Flocks RH, et al: Complications, results and problems of ileal conduit diversions. J Urol 109: 210 –214, 1973. 2. Marshall FF, Leadbetter WF, and Dretler SP: Ileal conduit parastomal hernias. J Urol 114: 40 – 46, 1975. 3. Hopkins TB, and Trento A: Parastomal ileal loop hernia repair with marlex mesh. J Urol 128: 811– 812, 1982. 4. Rubin MS, Schoetz DJ, and Matthews JB: Parastomal hernia: is stoma relocation superior to fascial repair. Arch Surg 129: 413– 417, 1994.
553
TECHNIQUE OF PARASTOMAL HERNIA REPAIR USING SYNTHETIC MESH MICHAEL E. FRANKS
AND
RONALD L. HREBINKO, JR
ABSTRACT We describe a reliable and simple technique of parastomal hernia repair using primary fascial repair with synthetic mesh that minimizes the known complications of infection and stomal stenosis while eliminating the need for peritoneal exploration, lysis of adhesions, and relocation of the stoma. We applied this technique to 6 patients (aged 65 to 83 years) with symptomatic, first-time parastomal hernias. The results are discussed. UROLOGY 57: 551–553, 2001. © 2001, Elsevier Science Inc.
P
arastomal hernia (PSH) after ileal loop diversion is a common occurrence, with a reported incidence of 2% to 6.5%.1–3 The urologic and general surgical literature contain surprisingly little information on the technique of PSH repair. Hopkins and Trento3 in 1982 were the first to use an in situ or local repair and synthetic mesh for PSH after ileal loop diversion. Their case report involved extensive intraperitoneal dissection and mobilization, with postoperative dermatitis and abscess formation. We describe a straightforward alternative method of local fascia repair with synthetic mesh onlay for patients with first-time PSH. MATERIAL AND METHODS Before surgery, a loopogram, intravenous urogram, and computed tomography (CT) scan are carried out. These procedures define concomitant abnormalities that may be repaired at the time of herniorrhaphy such as upper tract transitional cancer, obstruction, or stomal stenosis. The urine is cultured 7 to 10 days before surgery, either from a fresh stoma bag or (preferably) from sterile loop catheterization. Oral antibiotic agents are started 5 days preoperatively based on the reported sensitivities. Broad-spectrum intravenous antibiotic agents are given before the skin incision and continued for 24 to 48 hours postoperatively. At the time of surgery, the stoma appliance is removed and the stoma is prepped into the operative field. An 8 to 10-cm incision is made inferior and lateral to the skin mark made by the patient’s stoma wafer (Fig. 1). Dissection proceeds around the subcutaneous portion of the ileal loop. The hernia sac, From the Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Reprint requests: Ronald L. Hrebinko, Jr., M.D., 5200 Centre Avenue, Medical Center Building, Suite 209, Pittsburgh, PA 15232 Submitted: July 28, 2000, accepted (with revisions): October 16, 2000 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. Incision lateral to stoma and parastomal hernia. 0090-4295/01/$20.00 PII S0090-4295(00)01014-1 551
FIGURE 2. Hernia sac exposed deep to Scarpa’s fascia.
FIGURE 4. Synthetic mesh tailored.
FIGURE 3. Primary fascial closure after reduction of hernia sac.
which is usually lateral to the loop because of the mesenteric location, is identified, cleaned, and reduced or excised (Fig. 2). The fascial defect is further defined using sharp dissection and reapproximated prior to mesh onlay, if possible, using 2-0 interrupted, monofilament sutures (Fig. 3). If there is too much tension to reapproximate the fascial edges, we proceed with mesh onlay without fascial closure. A piece of nonabsorbable synthetic mesh (Marlex; CR Bard, Billerica, Mass) is soaked in povidine solution, cut carefully in a keyhole configuration (Fig. 4), and positioned to fit around the loop, its mesentery, and the fascial defect. Care is taken to 552
FIGURE 5. Mesh sutured in place to reinforce repair.
avoid constriction of the bowel and its mesenteric blood supply. Nonabsorbable monofilament 2-0 sutures are used to tack the mesh to the underlying fascia (Fig. 5). A closed drain is placed superficial to the mesh, the wound is closed in two layers, and the stoma appliance is replaced. UROLOGY 57 (3), 2001
RESULTS We used this technique on 6 patients, aged 65 to 83 years. Length of hospitalization was 2.5 days (range 2 to 5). At a mean follow-up of 26 months (range 2 to 42), there were no recurrences on follow-up examination or by CT scan, no mesh infections, and no stoma or loop stenoses. COMMENT Technical details of repair of PSH are often absent from surgical atlases, texts, or journal articles. Most articles are found in the general surgery literature and describe repair of PSH associated with enteral stomas, rather than urinary stomas. Rubin et al.4 have evaluated the techniques of primary repair, stoma relocation, or primary repair using synthetic mesh, and found that recurrence was common after all procedures, but more likely after primary repair alone (76% recurrence at 31 months). Importantly, stoma relocation was associated with a complication rate of up to 88%. Our
UROLOGY 57 (3), 2001
method, which uses an extrafascial approach, avoids the multiple incisions and associated morbidity associated with stomal relocation or intraperitoneal in situ repairs. CONCLUSIONS We describe a simple technique of PSH repair that can be completed in 2 to 3 hours. There were no postoperative stomal stenoses or recurrent hernias and, with careful attention to preoperative cultures, no infections. REFERENCES 1. Schmidt JD, Hawtrey CE, Flocks RH, et al: Complications, results and problems of ileal conduit diversions. J Urol 109: 210 –214, 1973. 2. Marshall FF, Leadbetter WF, and Dretler SP: Ileal conduit parastomal hernias. J Urol 114: 40 – 46, 1975. 3. Hopkins TB, and Trento A: Parastomal ileal loop hernia repair with marlex mesh. J Urol 128: 811– 812, 1982. 4. Rubin MS, Schoetz DJ, and Matthews JB: Parastomal hernia: is stoma relocation superior to fascial repair. Arch Surg 129: 413– 417, 1994.
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