- Email: [email protected]
Use of biologic mesh for a complicated paracolostomy hernia
The American Journal of Surgery (2008) 196, 715–719
The Association of VA Surgeons
Use of biologic mesh for a complicated paracolostomy hernia Emanuele Lo Menzo, M.D., Ph.D.a,*, Jose M. Martinez, M.D.a, Seth A. Spector, M.D.a, Alberto Iglesias, M.D.a, Vincent DeGennaro, M.D.a, Alessandro Cappellani, M.D.b a
Miami VA Healthcare System, University of Miami, Miller School of Medicine, Miami, FL, USA; bDepartment of Surgical Pathophysiology, University of Catania, Catania, Italy KEYWORDS: Paracolostomy hernia; Recurrence; Biologic mesh; Mesh
Abstract BACKGROUND: Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. Because the traditional surgical options of primary repair with or without ostomy repositioning have led to disappointing results, the use of mesh is indicated, especially in the setting of multiple recurrences. METHODS: After laparoscopic lyses of adhesions, the colostomy is pushed against the lateral abdominal wall, and a bovine pericardium graft is gently stretched and draped over the colostomy (the Sugarbaker technique). Transfascial sutures and tacks are placed along the perimeter of the mesh and around the colon to prevent small bowel herniation. RESULTS: The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up, the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results. CONCLUSION: Although several studies indicate the feasibility and efficacy of synthetic permanent mesh repair, the concerns of mesh infection, erosion, and ostomy obstruction still persist. The authors suggest parietalizing the bowel and using a biologic mesh. Published by Elsevier Inc.
Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. The reported incidence varies from 30% to 40% depending on the length of follow-up.1,2 Besides the well-known devastating but fortunately more rare complications of intestinal incarceration and strangulation, the majority of patients present with less severe, but not necessarily less disabling, complaints. These include local pain, skin irritation, an inability to keep colostomy appliances in place, restrictions * Corresponding author: Tel.: ⫹1-305-575-3244; fax: ⫹1-305-575-3255. E-mail address: [email protected] Manuscript received May 15, 2008; revised manuscript July 2, 2008
0002-9610/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.amjsurg.2008.07.012
of physical and daily life activities, and worsening of an already altered body image.2 Although technical factors (ie, large fascial opening, positioning of the ostomy outside the rectus muscle or too close to bony prominence) play a key role in the development of paracolostomy hernias,2 systemic factors such as obesity, immunosuppression, steroid therapy, local radiation treatment, infection, and malnutrition contribute significantly. The traditional surgical options of primary repair of these hernias with or without ostomy repositioning have led to disappointing results.3 Recent reports indicate the feasibility and efficacy of synthetic permanent mesh repairs. Similar to other types of ventral hernias, a variety of surgical techniques have
716
The American Journal of Surgery, Vol 196, No 5, November 2008
Figure 1 Computed tomographic scan with herniated small bowel through a widened mesh.
Figure 2 Intraoperative view of herniated bowel through widened ePTFE mesh.
been described. The techniques differ on the surgical approach, the mesh used, and the position and shape of the mesh. We report a novel approach for a recurrent paracolostomy hernia.
defect entirely exposed (Fig. 3). To minimize the area to “gap” with biologic mesh, transcutaneous nonabsorbable sutures are used to reduce the size of the defect itself (Fig. 4). The actual hernia repair is accomplished using acellular bovine pericardium mesh (Veritas; Synovis Surgical Innovations, St Paul, MN). Two nonabsorbable sutures are placed at the medial site of the mesh. The mesh is then introduced into the abdominal cavity through the 12-mm trocar. The mesh is first secured medially using a standard method of laparoscopic incisional hernia repair. The suture passer is introduced through a 2-mm skin incision. Both tails of the previously placed suture are sequentially withdrawn through the fascia, tied, and buried in the subcutaneous tissues. The colostomy is then pushed against the lateral abdominal wall, and the mesh is gently stretched and draped over the colostomy (Sugarbaker technique [I]). Using a spiral tack gun (ProTack; Autosuture, Covidien, Norwalk, CT), the mesh is fixed to the abdominal wall at 1-cm intervals. Additional transfascial nonabsorbable sutures are
Methods A 66-year-old man with a history of abdominoperineal resection for rectal cancer 12 years previously was seen in consultation for a 3-time recurrent paracolostomy hernia. His risk factors included obesity (body mass index, 33 kg/m2), hypertension, previous hernia repair with mesh, a history of radiation treatment, and cancer. Although all the repairs were performed at other institutions, the patient reported the use of a mesh for the last repair. The medical records from the other institutions and the information on the type of mesh previously used were not available preoperatively. We believe that preoperative imaging is important, especially in case of recurrent hernias (Fig. 1). We routinely use a second-generation cephalosporin preoperatively, and sequential compression devices were applied for deep venous thrombosis prophylaxis. The colostomy is covered with sterile gauze, and an iodine-impregnated film barrier (Ioban 3M Company, St Paul, MN) is also used to cover the entire operative field. The peritoneal cavity is accessed in the right upper quadrant under direct vision using a 5-mm optical trocar (Optiview; Ethicon EndoSurgery, Inc., Cincinnati, OH). Two additional 5-mm trocars are inserted in the right mid and lower quadrants. A 12-mm trocar is later inserted in the subxiphoid position, if additional retraction is necessary. After lyses of adhesions, several loops of small bowel are found to herniate through the hernia defect. In the recurrent hernia depicted, the previously placed keyhole mesh of expanded polytetrafluoroethylene (ePTFE) mesh is visible (Fig. 2). The small bowel is carefully reduced back in the abdominal cavity, and the
Figure 3
Hernia defect after lyses of adhesions.
E. Lo Menzo et al.
Figure 4
Biologic mesh for paracolostomy hernia
Reapproximation of defect with transfascial sutures.
placed along the lateral border of the colon to prevent small-bowel herniation (Fig. 5).
Results The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results (Fig. 6).
Comments Parastomal hernias are a challenging problem. The incidence varies from 30% to 40%, depending on the length of follow-up.1,2 Severe but less frequent complications include intestinal incarceration and strangulation, but the majority of patients present most commonly with local pain, skin
Figure 5 Transfascial nonabsorbable sutures along the lateral border of the colon to prevent small-bowel herniation.
717
Figure 6
Postoperative results.
irritation, inability to keep colostomy appliances in place, restrictions of physical and daily life activities, and worsening of an already altered body image.2 The technical factors that contribute to the development of this type of hernia are a large fascial opening, positioning of the ostomy outside the rectus muscle, or its placement too close to bony confinement.2 Systemic factors such as obesity, immunosuppression, steroid therapy, local radiation treatment, infection, and malnutrition may play a key role in this type of abdominal wall defect. Because a certain degree of herniation is inevitable during the creation of a colostomy,4 the chance of having a symptomatic hernia is quite high (up to 40%2). Except for the extraperitoneal placement of the colostomy, all the other techniques are prone to a significant hernia occurrence.1,2 The therapeutic options include ostomy repositioning, primary repair, and, more recently, mesh repair. Ostomy relocation has been the traditional method for repair of parastomal hernias. The disadvantages of this technique include the potential loss of more bowel, which is problematic in certain cases; inadequate length and mobility of the bowel; and difficulty finding an appropriate new location. Also, a full laparotomy is potentially needed, with the risk for future incisional hernias and other postoperative complications.5 Furthermore, the potential risk factors leading to the initial hernia (aside of some specific technical issues) might remain; hence the disappointing results, with recurrence rates up to 33% to 40%.5 Primary repair has the advantage of requiring a less invasive procedure and then quicker recovery. Unfortunately, similar to the primary repairs of other abdominal wall hernias, the recurrence rates are prohibitive at 46% for first-time primary repairs and 76% for second-time recurrences.5 Similar to other abdominal wall hernias, the concept of tension-free repair using prosthetic material seems to be leading to better long-term results, especially for secondtime repairs.5–7
718
The American Journal of Surgery, Vol 196, No 5, November 2008
The use of prosthetic mesh is certainly not a panacea, and some authors have reported significant recurrences.8 Contrary to the more standardized technique for incisional hernia repair on the basis of the Rives-Stoppa repair,9 several types of parastomal hernia repairs have been described. Although some preperitoneal techniques have been described with good results,10 the 2 most popular approaches remain the keyhole technique and the parietalization of the mesh. The use of prosthetic meshes in an onlay position should probably be abandoned, because similar failures are expected as for incisional hernias. This technique, in fact, will violate the La Place law by placing the mesh on the outside of the pressure gradient area instead of using transmural pressure to keep the mesh in place. The keyhole technique requires the creation of a slit in the mesh to accommodate the ostomy. Unfortunately, as has been extensively reported, the slit inevitably widens over time.11 In spite of the numerous variations in shape of the keyhole, recurrences are to be expected.5 Furthermore, the close contact of the split ends of the mesh with the bowel wall could result in fibrosis with pain, obstruction, and erosion.12 The latter complication is particularly worrisome when stiffer polypropylene mesh is used and when the mesh is too tight around the ostomy.12 Because successful results in preventing and treating parastomal hernias come from the extraperitoneal route of the bowel itself, the technique of parietalization makes the most physiologic sense, in our opinion. The technique has been extensively described by Sugarbaker.13 It consists of securing the bowel wall against the lateral abdominal wall and then placing the mesh to cover it, creating a flap valve. A recent multi-institutional retrospective trial reported a recurrence rate of 4% with this technique.14 According to the description of the authors, a nonslit ePTFE mesh is placed intraperitoneally to provide a 5-cm overlay coverage of the defect. Also, because the overall mechanical result similar in concept to the Ripstein repair of rectal prolapse, this procedure is effective for stoma prolapse.15 We applied the principle of the Sugarbaker technique and the superior results of laparoscopic incisional hernia repair compared with the open, as our preferred method of repair of paracolostomy hernias.16 Although polypropylene and ePTFE meshes have been used for this technique,15 the fear of fibrosis and erosion led us to choose a mesh that has not been described to cause these complications. In fact, biologic meshes have been safely used in the repair of paraesophageal hernias, in which the constant movement of the diaphragm is a significant risk factor.17 The other advantage of using a remodeling mesh is the virtually zero chance of infection. The concept behind biologic meshes is to provide a collagen and other extracellular matrix scaffold in which the host fibroblasts can create angiogenesis and deposit new collagen. Our choice of using a biologic mesh derived from bovine pericardium (Veritas) was determined by the idea that the other products made of dermis (allogenic or xeno-
genic) have a tendency to remodel into elastin rather than collagen and lead to unsatisfactory cosmetic results and pseudorecurrences.18 The compliance of the mesh allows perfect contouring around the bowel wall without creating obstruction, at the same time avoiding herniation between the colon and the lateral abdominal wall (Fig. 5). Because the biologic mesh requires vascularized tissue to effectively complete the remodeling process, it is important to avoid bridging too large a gap.18 With this concept in mind, we decrease the surface to be bridged by applying transfascial sutures into the widened defect. The potential weakness of this technique includes the possibility of lack of complete remodeling in the area of contact with old meshes or other nonvascularized surfaces. This surface has been kept to a minimum by the transfascial sutures. The use of biologic mesh for this particular application has been previously described.19,20 In both reports, the biologic meshes were used as an onlay reinforcement of the primary repair. To our knowledge this is the first description of a completely laparoscopic paracolostomy hernia repair using a biologic mesh with the parietalization technique.
Conclusion Parastomal hernias are a challenging problem. The high rate of recurrence suggests the need for a mesh for their repair, especially after multiple recurrences. Because of the potential complications associated with prosthetic materials, we suggest parietalizing the bowel and using a biologic mesh. Finally, bridging large gaps with biologic graft should be avoided, and instead, complete and uniform contact with vascularized tissue should be provided.
References 1. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum 1994; 37:916 –20. 2. Cheung MT. Complications of an abdominal stoma: an analysis of 322 stomas. Aust N Z J Surg 1995;65:808 –11. 3. Cheung MT, Chia NH, Chiu WY. Surgical treatment of parastomal hernia complicating sigmoid colostomies. Dis Colon Rectum 2001;44: 266 –70. 4. Goligher J. Surgery of the anus, rectum and colon. 5th ed. London: Bailliere Tindall; 1985:703–5. 5. Rubin MS, Schoetz DJ Jr, Matthews JB. Parastomal hernia. Is stoma relocation superior to fascial repair? Arch Surg 1994;129: 413– 8. 6. Stelzner S, Hellmich G, Ludwig K. Repair of paracolostomy hernias with a prosthetic mesh in the intraperitoneal onlay position: modified Sugarbaker technique. Dis Colon Rectum 2004;47:185–91. 7. Hofstetter WL, Vukasin P, Ortega AE, et al. New technique for mesh repair of paracolostomy hernias. Dis Colon Rectum 1998;41:1054 –5.
E. Lo Menzo et al.
Biologic mesh for paracolostomy hernia
8. Geisler DJ, Reilly JC, Vaughan SG, et al. Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel. Dis Colon Rectum 2003;46:1118 –23. 9. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545–54. 10. Amin SN, Armitage NC, Abercrombie JF, et al. Lateral repair of parastomal hernia. Ann R Coll Surg Engl 2001;83:206 – 8. 11. Moisidis E, Curiskis JI, Brooke-Cowden GL. Improving the reinforcement of parastomal tissues with Marlex mesh: laboratory study identifying solutions to stomal aperture distortion. Dis Colon Rectum 2000;43:55– 60. 12. Aldridge AJ, Simson JN. Erosion and perforation of colon by synthetic mesh in a recurrent paracolostomy hernia. Hernia 2001;5:110 –2. 13. Sugarbaker PH. Prosthetic mesh repair of large hernias at the site of colonic stomas. Surg Gynecol Obstet 1980;150:576 – 8. 14. Mancini GJ, McClusky DA III, Khaitan L, et al. Laparoscopic parastomal hernia repair using a nonslit mesh technique. Surg Endosc 2007;21: 1487–91.
719 15. Voitk A. Simple technique for laparoscopic paracolostomy hernia repair. Dis Colon Rectum 2000;43:1451–3. 16. Pierce RA, Spitler JA, Frisella MM, et al. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc 2007;21:378 – 86. 17. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg 2006;244: 481–90. 18. Jin J, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg 2007;205:654 – 60. 19. Araujo SE, Habr-Gama A, Teixeira MG, et al. Role of biological mesh in surgical treatment of paracolostomy hernias. Clinics 2005; 60:271– 6. 20. Kish KJ, Buinewicz BR, Morris JB. Acellular dermal matrix (AlloDerm): new material in the repair of stoma site hernias. Am Surg 2005;71: 1047–50.
The Association of VA Surgeons
Use of biologic mesh for a complicated paracolostomy hernia Emanuele Lo Menzo, M.D., Ph.D.a,*, Jose M. Martinez, M.D.a, Seth A. Spector, M.D.a, Alberto Iglesias, M.D.a, Vincent DeGennaro, M.D.a, Alessandro Cappellani, M.D.b a
Miami VA Healthcare System, University of Miami, Miller School of Medicine, Miami, FL, USA; bDepartment of Surgical Pathophysiology, University of Catania, Catania, Italy KEYWORDS: Paracolostomy hernia; Recurrence; Biologic mesh; Mesh
Abstract BACKGROUND: Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. Because the traditional surgical options of primary repair with or without ostomy repositioning have led to disappointing results, the use of mesh is indicated, especially in the setting of multiple recurrences. METHODS: After laparoscopic lyses of adhesions, the colostomy is pushed against the lateral abdominal wall, and a bovine pericardium graft is gently stretched and draped over the colostomy (the Sugarbaker technique). Transfascial sutures and tacks are placed along the perimeter of the mesh and around the colon to prevent small bowel herniation. RESULTS: The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up, the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results. CONCLUSION: Although several studies indicate the feasibility and efficacy of synthetic permanent mesh repair, the concerns of mesh infection, erosion, and ostomy obstruction still persist. The authors suggest parietalizing the bowel and using a biologic mesh. Published by Elsevier Inc.
Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. The reported incidence varies from 30% to 40% depending on the length of follow-up.1,2 Besides the well-known devastating but fortunately more rare complications of intestinal incarceration and strangulation, the majority of patients present with less severe, but not necessarily less disabling, complaints. These include local pain, skin irritation, an inability to keep colostomy appliances in place, restrictions * Corresponding author: Tel.: ⫹1-305-575-3244; fax: ⫹1-305-575-3255. E-mail address: [email protected] Manuscript received May 15, 2008; revised manuscript July 2, 2008
0002-9610/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.amjsurg.2008.07.012
of physical and daily life activities, and worsening of an already altered body image.2 Although technical factors (ie, large fascial opening, positioning of the ostomy outside the rectus muscle or too close to bony prominence) play a key role in the development of paracolostomy hernias,2 systemic factors such as obesity, immunosuppression, steroid therapy, local radiation treatment, infection, and malnutrition contribute significantly. The traditional surgical options of primary repair of these hernias with or without ostomy repositioning have led to disappointing results.3 Recent reports indicate the feasibility and efficacy of synthetic permanent mesh repairs. Similar to other types of ventral hernias, a variety of surgical techniques have
716
The American Journal of Surgery, Vol 196, No 5, November 2008
Figure 1 Computed tomographic scan with herniated small bowel through a widened mesh.
Figure 2 Intraoperative view of herniated bowel through widened ePTFE mesh.
been described. The techniques differ on the surgical approach, the mesh used, and the position and shape of the mesh. We report a novel approach for a recurrent paracolostomy hernia.
defect entirely exposed (Fig. 3). To minimize the area to “gap” with biologic mesh, transcutaneous nonabsorbable sutures are used to reduce the size of the defect itself (Fig. 4). The actual hernia repair is accomplished using acellular bovine pericardium mesh (Veritas; Synovis Surgical Innovations, St Paul, MN). Two nonabsorbable sutures are placed at the medial site of the mesh. The mesh is then introduced into the abdominal cavity through the 12-mm trocar. The mesh is first secured medially using a standard method of laparoscopic incisional hernia repair. The suture passer is introduced through a 2-mm skin incision. Both tails of the previously placed suture are sequentially withdrawn through the fascia, tied, and buried in the subcutaneous tissues. The colostomy is then pushed against the lateral abdominal wall, and the mesh is gently stretched and draped over the colostomy (Sugarbaker technique [I]). Using a spiral tack gun (ProTack; Autosuture, Covidien, Norwalk, CT), the mesh is fixed to the abdominal wall at 1-cm intervals. Additional transfascial nonabsorbable sutures are
Methods A 66-year-old man with a history of abdominoperineal resection for rectal cancer 12 years previously was seen in consultation for a 3-time recurrent paracolostomy hernia. His risk factors included obesity (body mass index, 33 kg/m2), hypertension, previous hernia repair with mesh, a history of radiation treatment, and cancer. Although all the repairs were performed at other institutions, the patient reported the use of a mesh for the last repair. The medical records from the other institutions and the information on the type of mesh previously used were not available preoperatively. We believe that preoperative imaging is important, especially in case of recurrent hernias (Fig. 1). We routinely use a second-generation cephalosporin preoperatively, and sequential compression devices were applied for deep venous thrombosis prophylaxis. The colostomy is covered with sterile gauze, and an iodine-impregnated film barrier (Ioban 3M Company, St Paul, MN) is also used to cover the entire operative field. The peritoneal cavity is accessed in the right upper quadrant under direct vision using a 5-mm optical trocar (Optiview; Ethicon EndoSurgery, Inc., Cincinnati, OH). Two additional 5-mm trocars are inserted in the right mid and lower quadrants. A 12-mm trocar is later inserted in the subxiphoid position, if additional retraction is necessary. After lyses of adhesions, several loops of small bowel are found to herniate through the hernia defect. In the recurrent hernia depicted, the previously placed keyhole mesh of expanded polytetrafluoroethylene (ePTFE) mesh is visible (Fig. 2). The small bowel is carefully reduced back in the abdominal cavity, and the
Figure 3
Hernia defect after lyses of adhesions.
E. Lo Menzo et al.
Figure 4
Biologic mesh for paracolostomy hernia
Reapproximation of defect with transfascial sutures.
placed along the lateral border of the colon to prevent small-bowel herniation (Fig. 5).
Results The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results (Fig. 6).
Comments Parastomal hernias are a challenging problem. The incidence varies from 30% to 40%, depending on the length of follow-up.1,2 Severe but less frequent complications include intestinal incarceration and strangulation, but the majority of patients present most commonly with local pain, skin
Figure 5 Transfascial nonabsorbable sutures along the lateral border of the colon to prevent small-bowel herniation.
717
Figure 6
Postoperative results.
irritation, inability to keep colostomy appliances in place, restrictions of physical and daily life activities, and worsening of an already altered body image.2 The technical factors that contribute to the development of this type of hernia are a large fascial opening, positioning of the ostomy outside the rectus muscle, or its placement too close to bony confinement.2 Systemic factors such as obesity, immunosuppression, steroid therapy, local radiation treatment, infection, and malnutrition may play a key role in this type of abdominal wall defect. Because a certain degree of herniation is inevitable during the creation of a colostomy,4 the chance of having a symptomatic hernia is quite high (up to 40%2). Except for the extraperitoneal placement of the colostomy, all the other techniques are prone to a significant hernia occurrence.1,2 The therapeutic options include ostomy repositioning, primary repair, and, more recently, mesh repair. Ostomy relocation has been the traditional method for repair of parastomal hernias. The disadvantages of this technique include the potential loss of more bowel, which is problematic in certain cases; inadequate length and mobility of the bowel; and difficulty finding an appropriate new location. Also, a full laparotomy is potentially needed, with the risk for future incisional hernias and other postoperative complications.5 Furthermore, the potential risk factors leading to the initial hernia (aside of some specific technical issues) might remain; hence the disappointing results, with recurrence rates up to 33% to 40%.5 Primary repair has the advantage of requiring a less invasive procedure and then quicker recovery. Unfortunately, similar to the primary repairs of other abdominal wall hernias, the recurrence rates are prohibitive at 46% for first-time primary repairs and 76% for second-time recurrences.5 Similar to other abdominal wall hernias, the concept of tension-free repair using prosthetic material seems to be leading to better long-term results, especially for secondtime repairs.5–7
718
The American Journal of Surgery, Vol 196, No 5, November 2008
The use of prosthetic mesh is certainly not a panacea, and some authors have reported significant recurrences.8 Contrary to the more standardized technique for incisional hernia repair on the basis of the Rives-Stoppa repair,9 several types of parastomal hernia repairs have been described. Although some preperitoneal techniques have been described with good results,10 the 2 most popular approaches remain the keyhole technique and the parietalization of the mesh. The use of prosthetic meshes in an onlay position should probably be abandoned, because similar failures are expected as for incisional hernias. This technique, in fact, will violate the La Place law by placing the mesh on the outside of the pressure gradient area instead of using transmural pressure to keep the mesh in place. The keyhole technique requires the creation of a slit in the mesh to accommodate the ostomy. Unfortunately, as has been extensively reported, the slit inevitably widens over time.11 In spite of the numerous variations in shape of the keyhole, recurrences are to be expected.5 Furthermore, the close contact of the split ends of the mesh with the bowel wall could result in fibrosis with pain, obstruction, and erosion.12 The latter complication is particularly worrisome when stiffer polypropylene mesh is used and when the mesh is too tight around the ostomy.12 Because successful results in preventing and treating parastomal hernias come from the extraperitoneal route of the bowel itself, the technique of parietalization makes the most physiologic sense, in our opinion. The technique has been extensively described by Sugarbaker.13 It consists of securing the bowel wall against the lateral abdominal wall and then placing the mesh to cover it, creating a flap valve. A recent multi-institutional retrospective trial reported a recurrence rate of 4% with this technique.14 According to the description of the authors, a nonslit ePTFE mesh is placed intraperitoneally to provide a 5-cm overlay coverage of the defect. Also, because the overall mechanical result similar in concept to the Ripstein repair of rectal prolapse, this procedure is effective for stoma prolapse.15 We applied the principle of the Sugarbaker technique and the superior results of laparoscopic incisional hernia repair compared with the open, as our preferred method of repair of paracolostomy hernias.16 Although polypropylene and ePTFE meshes have been used for this technique,15 the fear of fibrosis and erosion led us to choose a mesh that has not been described to cause these complications. In fact, biologic meshes have been safely used in the repair of paraesophageal hernias, in which the constant movement of the diaphragm is a significant risk factor.17 The other advantage of using a remodeling mesh is the virtually zero chance of infection. The concept behind biologic meshes is to provide a collagen and other extracellular matrix scaffold in which the host fibroblasts can create angiogenesis and deposit new collagen. Our choice of using a biologic mesh derived from bovine pericardium (Veritas) was determined by the idea that the other products made of dermis (allogenic or xeno-
genic) have a tendency to remodel into elastin rather than collagen and lead to unsatisfactory cosmetic results and pseudorecurrences.18 The compliance of the mesh allows perfect contouring around the bowel wall without creating obstruction, at the same time avoiding herniation between the colon and the lateral abdominal wall (Fig. 5). Because the biologic mesh requires vascularized tissue to effectively complete the remodeling process, it is important to avoid bridging too large a gap.18 With this concept in mind, we decrease the surface to be bridged by applying transfascial sutures into the widened defect. The potential weakness of this technique includes the possibility of lack of complete remodeling in the area of contact with old meshes or other nonvascularized surfaces. This surface has been kept to a minimum by the transfascial sutures. The use of biologic mesh for this particular application has been previously described.19,20 In both reports, the biologic meshes were used as an onlay reinforcement of the primary repair. To our knowledge this is the first description of a completely laparoscopic paracolostomy hernia repair using a biologic mesh with the parietalization technique.
Conclusion Parastomal hernias are a challenging problem. The high rate of recurrence suggests the need for a mesh for their repair, especially after multiple recurrences. Because of the potential complications associated with prosthetic materials, we suggest parietalizing the bowel and using a biologic mesh. Finally, bridging large gaps with biologic graft should be avoided, and instead, complete and uniform contact with vascularized tissue should be provided.
References 1. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum 1994; 37:916 –20. 2. Cheung MT. Complications of an abdominal stoma: an analysis of 322 stomas. Aust N Z J Surg 1995;65:808 –11. 3. Cheung MT, Chia NH, Chiu WY. Surgical treatment of parastomal hernia complicating sigmoid colostomies. Dis Colon Rectum 2001;44: 266 –70. 4. Goligher J. Surgery of the anus, rectum and colon. 5th ed. London: Bailliere Tindall; 1985:703–5. 5. Rubin MS, Schoetz DJ Jr, Matthews JB. Parastomal hernia. Is stoma relocation superior to fascial repair? Arch Surg 1994;129: 413– 8. 6. Stelzner S, Hellmich G, Ludwig K. Repair of paracolostomy hernias with a prosthetic mesh in the intraperitoneal onlay position: modified Sugarbaker technique. Dis Colon Rectum 2004;47:185–91. 7. Hofstetter WL, Vukasin P, Ortega AE, et al. New technique for mesh repair of paracolostomy hernias. Dis Colon Rectum 1998;41:1054 –5.
E. Lo Menzo et al.
Biologic mesh for paracolostomy hernia
8. Geisler DJ, Reilly JC, Vaughan SG, et al. Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel. Dis Colon Rectum 2003;46:1118 –23. 9. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545–54. 10. Amin SN, Armitage NC, Abercrombie JF, et al. Lateral repair of parastomal hernia. Ann R Coll Surg Engl 2001;83:206 – 8. 11. Moisidis E, Curiskis JI, Brooke-Cowden GL. Improving the reinforcement of parastomal tissues with Marlex mesh: laboratory study identifying solutions to stomal aperture distortion. Dis Colon Rectum 2000;43:55– 60. 12. Aldridge AJ, Simson JN. Erosion and perforation of colon by synthetic mesh in a recurrent paracolostomy hernia. Hernia 2001;5:110 –2. 13. Sugarbaker PH. Prosthetic mesh repair of large hernias at the site of colonic stomas. Surg Gynecol Obstet 1980;150:576 – 8. 14. Mancini GJ, McClusky DA III, Khaitan L, et al. Laparoscopic parastomal hernia repair using a nonslit mesh technique. Surg Endosc 2007;21: 1487–91.
719 15. Voitk A. Simple technique for laparoscopic paracolostomy hernia repair. Dis Colon Rectum 2000;43:1451–3. 16. Pierce RA, Spitler JA, Frisella MM, et al. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc 2007;21:378 – 86. 17. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg 2006;244: 481–90. 18. Jin J, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg 2007;205:654 – 60. 19. Araujo SE, Habr-Gama A, Teixeira MG, et al. Role of biological mesh in surgical treatment of paracolostomy hernias. Clinics 2005; 60:271– 6. 20. Kish KJ, Buinewicz BR, Morris JB. Acellular dermal matrix (AlloDerm): new material in the repair of stoma site hernias. Am Surg 2005;71: 1047–50.