Comparing Sugarbaker versus keyhole mesh technique for open retromuscular parastomal hernia repair: study protocol for a registry-based randomized controlled trial

BackgroundParastomal hernia, common after stoma creation, negatively impacts patient quality of life. For patients with a permanent stoma, durable parastomal hernia repair remains a challenge, with few high-quality studies for guidance. An alternative to open retromuscular parastomal hernia repair with retromuscular “keyhole” mesh is the recent Sugarbaker modification. We aim to compare these two techniques in a head-to-head prospective study.MethodsThis is a registry-based randomized controlled trial designed to investigate whether the retromuscular Sugarbaker technique is superior to the retromuscular keyhole technique for parastomal hernia repair. The primary study endpoint is parastomal hernia recurrence at two years. Secondary endpoints include hospital length-of-stay, readmission, wound morbidity, mesh-related complications, re-operation, all 30-day morbidity, and patient-reported outcomes, including hernia-related quality of life, stoma-specific quality of life, pain, and decision regret.DiscussionBased on the post hoc analysis of a recent randomized controlled trial, we hypothesize that the retromuscular Sugarbaker technique will reduce parastomal hernia recurrence by 20% at 2 years compared to the retromuscular keyhole mesh technique. The results of this study may provide evidence-based guidance for surgeons repairing parastomal hernias.Trial registrationClinicalTrials.gov NCT03972553. Registered June 3, 2019.

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a randomised controlled trial

Background Parastomal hernia is a common complication of an enterostomy and can have a significant impact on health-related quality of life. Currently used methods of repair have high recurrence rates and considerable risk for complications. We have developed a new technique for parastomal hernia repair that uses full-thickness skin graft as reinforcement. Methods This study protocol describes a multicentre randomised controlled trial on parastomal hernia repair comparing a new full-thickness skin graft technique with conventional synthetic composite mesh as reinforcement of the abdominal wall. Patients with a symptomatic parastomal hernia will be included and followed up at 3, 12 and 36 months, with surgical complication as the primary outcome. Secondary outcomes will be recurrence rate and health-related quality of life assessed with VHPQ, EORTC C30 and CR29. Tissue biology and collagen metabolism will be investigated pre- and postoperatively using biopsies of the abdominal wall fascia and blood samples. Discussion Parastomal hernia constitutes a major clinical problem where the prospects of a good result after hernia repair are presently poor. This new method of repair with full-thickness skin grafting could be a new alternative in our surgical toolbox, but before then, it must be evaluated properly. Trial registration ClinicalTrials.gov NCT03667287. Registered on September 12, 2018

Surgical treatment of stoma-related hernias: retrospective cohort study of damage claims to the Swedish National Patient Insurance Company 2010–2016

Background Parastomal hernia and stoma-site hernia are common stoma complications. Parastomal hernia repair is associated with high complication and recurrence rates. Insurance data can provide novel information on the consequences of perioperative complications from the patient’s point of view. The aim was to investigate what types of complications associated with stoma-related hernia surgery that cause patients to apply for economic compensation through the patient insurance system and to investigate demographic and clinical differences among cases based on gender and type of center at which the surgery was performed. Methods A national patient damage claim database was searched for ICD-10 codes related to parastomal and stoma-site hernia surgery over a seven-year period. Medical records were screened for claims associated with parastomal hernia repair, relocation or reversal due to parastomal hernia, or stoma-site hernia repair. Claims were classified according to one of four primary complaints: surgical, anesthetic, medical or other. Clinical and demographic differences between genders and hospital types were investigated. Reasons for non-compensation were analyzed. Results Thirty claims met the inclusion criteria. Eighteen were related to parastomal hernia repair, seven to stoma-site hernia repair, three to stoma reversal and two to relocation due to parastomal hernia. Twenty-five claims were primarily surgical, two related to anesthesia and three classified as other. Seven claims were granted compensation. No demographic or clinical differences were found apart from female gender being associated with previous parastomal hernia repair [6 women and 0 men (p = 0.02)]. Conclusion Surgical complaints predominated. Few claims were compensated, reflecting the complexity and unsatisfactory outcomes of these procedures. Many claims were identified in relation to the incidence of stoma-related hernia surgery. Trial registration Due to its retrospective and descriptive nature, the study was not registered in any registry.

OV18 ENDOSCOPIC RETRO-MUSCULAR REPAIR OF PARASTOMAL HERNIA - A TANTALIZING NEW TECHNIQUE

Development of retro muscular space with transversus abdominis release has reached maturity in endoscopic surgery. Next-level reconstruction is adaptation to parastomal hernia repair alone or in conjunction with another abdominal wall hernia repair. We aim to present this extraperitoneal modified mesh technique based on the Sugarbaker principle with video demonstration and share clinical data and results from twenty-four patients operated with this technique within two years from the spring of 2019 to the spring of 2021. 77% patients had para-colostomy hernia and 41% of the patients had accessory repairs for midline or opposite flank hernia. 18% had prophylactic mesh at index operation, 27% were recurrent parastomal hernia and ostomies were formed median 32 months prior to parastomal hernia repair. 72% of the patients were operated robotically and 28% laparoscopically. Median follow up at time for presentation will be 17 months.

OV02 COMPLEX PARASTOMAL HERNIA REPAIR WITH MESH FISTULA AND MESH INFECTION

Aim Parastomal hernias of any size can be difficult to manage and greatly affect a patient’s quality of life, however, they can be even more problematic when associated with loss of domain and infection. The aim of our video was to demonstrate open repair of a massive parastomal hernia complicated by loss of domain, mesh fistula, and mesh infection. Material and Methods Images and footage from clinic and the operative procedure were included. Results A 51-year-old female with a history of prior APR followed by failed ventral and parastomal hernia repairs presented with a massive parastomal hernia that was significantly impacting her and her family’s quality of life. Due to her hernia, she had become immobile and was bed bound. Furthermore, the hernia had caused significant chronic constipation secondary to colonic dysmotility. The patient also had loss of domain, and her hernia appeared to be complicated by a chronic mesh infection with a draining sinus. She underwent pre-operative bilateral botulinum toxin A injection in the oblique abdominal musculature. She then underwent open preperitoneal parastomal hernia repair with biologic mesh, excision of prior mesh, primary fistula repair, total abdominal colectomy, and end ileostomy. The patient tolerated the procedure well without complications and has continued to do well in follow-up. She has had great improvement in her quality of life. Conclusions In this patient with a massive parastomal hernia complicated by loss of domain, mesh fistula, and mesh infection, we demonstrate a successful open preperitoneal repair following pre-operative BTA injection.

P083 PARASTOMAL HERNIA REPAIR - EXPERIENCES WITH THE MODIFIED RETROMUSCULAR SUGARBAKER TECHNIQUE

Aim Parastomal hernias are complex findings with a high recurrence rate. Various methods were described for surgical repair. A new method for the treatment of parastomal hernias with extraperitoneal mesh placement was published in 2016 (Pauli et al.). Recently, open retromuscular repair has been shown to be safe, effective and durable (Beffa et al. 2017). Still, there are concerns regarding mesh related complications (Tastaldi et al. 2017). Material and Methods All patients who underwent an open or laparoscopic modified retromuscular Sugarbaker parastomal hernia repair at our institution were identified. We describe the patient characteristics, operative details, perioperative results and the follow-up. Results Between January 2018 to May 2021 14 patients received surgical repair for parastomal hernia at our institution. Eight of these patients received retromuscular extraperitoneal mesh placement (4 open, 4 laparoscopic) in the aforementioned technique. The median age was 72 years (65 – 85) and the median BMI was 31 kg/m² (26 – 34). Six patients had a urostomy and two had a colostomy. One patient had a recurrent parastomal hernia after previous intraabdominal mesh repair. The median operating time was 223 minutes (144 – 425). Median Mesh size was 300 cm² (225 – 750). Two minor complications (Clavien-Dindo Classification Grade II) demanding pharmacological treatment. The median hospital stay was 8 days (4 – 17). Median follow up was 17 month (range 1 – 26). Recurrence rate was 25 %. Conclusions The modified retromuscular sugerbaker technique seems to be safe and feasible as shown by our data. Due to the extraperitoneal mesh position, we see fundamental methodological advantages. Further studies are necessary for long-term results.

Modified Laparoscopic Sugarbaker Repair of Parastomal Hernia With a Totally Extraperitoneal Technique

Purpose: Many patients develop a parastomal hernia within the first 2 years of stoma formation, and even surgical repair is associated with high recurrence rates. An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia; it is unknown whether a totally extraperitoneal technique (TEP) is feasible. Here we describe a laparoscopic TEP approach using a modified Sugarbaker method for the repair of parastomal hernia.Methods: Seven patients underwent parastomal hernia repair. The retrograde puncture technique was used to create the extrapneumoperitoneum, and the peritoneum was separated with a laparoscopic TEP approach; the mesh was placed using a modified Sugarbaker technique.Results: All patients had an oncologic etiology for stoma creation. The mean (±SD) size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm2. The mean operative time was 195.5 ± 20.7 min and average length of hospital stay after surgery was 4.8 ± 2.1 days. One patient had intraoperative subcutaneous emphysema. The average follow-up time was 8.5 ± 2.7 months; mild pain occurred in 2 patients, 3 experienced seroma formation (with no special treatment required), and 1 had early intestinal obstruction (which was treated with conservative care). There was no hernia recurrence, wound complications, or infections of the surgical site or mesh during follow-up.Conclusion: A laparoscopic TEP technique is technically challenging but feasible. Modified laparoscopic Sugarbaker repair of a parastomal hernia with the TEP technique is safe and effective, although the recurrence rate and late complications require confirmation in more cases with long-term follow-up.