Laparoscopic stoma relocation for parastomal hernia treatment by using a magnetic resonance visible three‐dimensional implant

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Excerpt

Parastomal hernias (PSH) are a common and frequent complication after permanent stoma construction and continue to be a distressing problem for patients. PSH are a major clinical problem after permanent stoma formation with a reported incidence up to 50% in clinical examination and even 78% when looked for with the help of computed tomography.1 They remain a surgical challenge despite the progress concerning various techniques for surgical repair.2 Looking at the excellent results of PSH prevention with a pre‐shaped funnel device to keep the bowel with reinforcement of the surrounding tissues,3 we assumed that the use of this device may also be beneficial in the repair of PSH.
We report on a male 74‐year‐old patient with a large symptomatic parastomal hernia (defect size 5 × 4 cm). The patient had undergone a rectum amputation with a left‐sided permanent colostomy 2 years earlier. The patient was in supine position with mild hyperlordosis. The operative technique was performed as follows: we started with the insertion of three ports on the contralateral side of the ostomy using a 10 mm/30° angle laparoscope. It is important to dissect not only the stoma region but also the anterior abdominal wall above all the midline to expose any incidental incisional hernias. If the laparoscopic dissection and reduction of the hernia sac content is very tricky because of PSH recurrences possibly after previous mesh‐based repairs, adhesions, scarring and bowel adherence, the laparoscopic preparation can remain incomplete because a small localized open approach at the stoma side is anyway required. Based on this circular incision around the ostomy, an additional dissection coming from outside the peritoneal cavity is easily possible. We preliminary closed the ostomy with sutures and performed the hernia sac excision, dissection of adherent and scarring tissue, and reduction of the hernia sac content. Afterwards, the stoma bowel was reduced to the suitable length and brought out through a quadratic 3‐D funnel mesh with 16 cm side length and 3 cm funnel diameter. Subsequently, the ostomy was relocated equilaterally through the pre‐existing hernia hole. The fascial defect was narrowed with interrupted sutures. Eventually, the mesh was spread out after conversion to the laparoscopic approach and placed in intraperitoneal onlay technique. The funnel must be directed to the abdominal cavity (arrow on Fig. 1). The fixation took place with absorbable strap devices (Ethicon SecureStrap™, Johnson and Johnson Medical Products GmbH, Vienna, Austria) in a double crown technique at the edges of the flat part of the mesh and around the stoma. Finally, the new ostomy was fixed on the skin with everting mucocutaneous sutures. The patient's post‐operative course was uneventful.
The 3‐D mesh can be used in laparoscopy, in laparoscopically assisted and in open surgery, and the implant can be placed easily and quickly. The PSH defect can be covered locally with a wide overlap to all sides. The positive effect on prolapse prevention arises from the dome, which is directed towards the abdominal cavity and fits to the bowel tightly. The layers of the abdominal wall do not need to be separated. The localized peristomal approach easily allows for complete excision of the hernia sac for seroma prevention and secondly the narrowing of the fascia defect provides a better ‘landing zone’ for the underlying flat part of the funnel mesh.
The Dynamesh™, IPST® implant (FEG Textiltechnik, Aachen, Germany) is a 3‐D preshaped, specially designed macroporous (>1 mm) and monofilament mesh, consisting of visceral‐sided polyvinylidene fluoride4 and parietal‐sided polypropylene.

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