BACKGROUND: Parastomal hernias present a common complex surgical problem that has a severe clinical impact on quality of life. Several techniques for repair have been described with open or minimally invasive techniques, although recurrence and reoperation continue to be common problems. In the following, a case series utilizing a technique for a minimally invasive repair using the Di Vinci robotic platform for a mesh-reinforced, modified Sugarbaker repair is described. STUDY DESIGN: This study is a retrospective review of 24 cases of robotic-assisted parastomal hernia repairs performed by a single surgeon from 2014 to 2020. Primary endpoints of interest were operative times and length of stay, as well as postoperative complications. RESULTS: Twenty-four patients were included in the study. The average operative time was 194.8 min (range: 95–378 min) and the average console time was 149.5 min (range: 72–319 min). The average length of stay was 3.9 days. No patients required conversion to either a laparoscopic or an open procedure, although two complications required reoperation. Twelve patients developed minor complications, including four who developed a postoperative seroma, but none of them required surgical intervention. CONCLUSIONS: This is the first and largest series describing a technique for a robotic-assisted parastomal hernia repair. This shows that this procedure can be reliably undertaken with the robotic platform with consistent and reproducible results and few complications. Further long-term research will be needed as new robotic techniques evolve and patients will need follow-up regarding recurrence rates and any late complications evaluated.
Keywords: Hernia, minimally invasive, parastomal, repair, robotic
| Introduction|| |
Parastomal hernia is a frequent complication following the construction of a colostomy or an ileostomy, occurring in at least 50% of patients.,, This type of incisional hernia involves protrusion of abdominal contents through the abdominal wall defect created during ostomy formation. The reported incidence of parastomal hernia varies depending on the literature referenced and is related to the type of ostomy constructed and the ensuing follow-up period. Previous rates of parastomal hernia formation for end-ileostomy at 0.8%–28.3% and for end-colostomy have ranged between 4.0% and 48.1%. The mere presence of a parastomal hernia does not always mandate repair, but surgical repair is indicated when complications develop including obstruction/strangulation/infarction and chronic symptoms that impair their quality of life (e.g. poor ostomy appliance seal). Approaches to surgical management of parastomal hernia vary widely, although most are derived from three concepts, including primary repair, mesh reinforcement, and stoma relocation.
The various techniques of laparoscopic parastomal hernia repair are well described in the literature.,, The “keyhole” repair has proven to be associated with a very high recurrence rate and is avoided in most cases.,,, We favor a mesh repair using a Sugarbaker technique that uses an intraperitoneal mesh over the entire fascial defect placed circumferentially and laterally. This repair creates a mesh “flap” valve around the stoma and lateralized bowel. With the advent of robotic surgery to the repertoire of the minimally invasive surgeon, a technique for minimally invasive robotic repair has been adopted by our group with modifications in our prior laparoscopic Sugarbaker repair.,,
Parastomal hernia remains a common clinical problem from ostomy creation. Unlike a classical incisional hernia development, which is a failure of healing between tissues that have been approximated, ostomy creation introduces an abdominal wall defect, the trephine, for which no final closure is feasible. As forces of the abdominal wall musculature tangential to the circumference of the trephine increase, the size of the trephine results in enlargement of the defect, which then allows herniation of abdominal contents. The primary etiology of this event varies widely and depends upon numerous patient factors related to method of ostomy creation, case characteristics (emergency vs. elective), surgical technique for ostomy construction (open vs laparoscopic), fascial integrity, concomitant procedures at the time of ostomy creation, and others.
In the following, we present a case series for a technique of minimally invasive repair of parastomal hernia of ileostomy, urostomy, and colostomy utilizing the Da Vinci Robotic Surgical Platform (Intuitive Surgical, Sunnyvale, CA, USA). Intracorporeal adhesiolysis and lateralization of the bowel with a modified Sugarbaker mesh configuration within the intraperitoneal space is described. This technique allows a single surgeon to perform the operation and place the mesh for the repair of the parastomal hernia.
| Materials and Methods|| |
After institutional review board approval, all cases from October 2014 to February 2020 of a single surgeon (KAL) at our institution (Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA) were reviewed. Twenty-four patients who underwent a robotic parastomal hernia repair were identified and a thorough chart review was performed. Baseline characteristics including demographics, comorbidities, operative times, smoking status, and specific procedure details were tallied. The length of stay, operative time, and console time were considered as primary endpoints and any postoperative complications were monitored.
Data analysis and statistics
All initial data were collected prior to the start of the procedure. All operative times were recorded based on operating room records of entry and exit from the room. Intraoperative record of beginning and ending of console operation was recorded based on direct direction of the surgeon. These along with all pertinent pre- and postoperative characteristics were tabulated and averaged. All calculations were made using Excel basic statistics software.
With the patient supine, general endotracheal anesthesia is induced and the stoma is closed with a running silk suture. The lone exception is the urostomy, into which a Foley catheter is placed. The site of the ostomy appliance is marked with a skin marking pencil. This is done to allow the surgeon to identify the location of any potential skin incisions to place the mesh or reduce irreducible contents if needed. The abdomen is prepped and draped in a standard sterile fashion. Abdominal entry is achieved with a 5-mm optical trocar in an upper quadrant (usually right) to evaluate the amount of adhesions and to achieve optimum locations of the additional 8 mm robotic trocars on the side of the abdomen opposite of the stoma location [Figure 1]. A 12-mm trocar (with AirSeal [Conmed, Largo, FL, USA] used on occasion) is placed in the upper quadrant. This is used for needle introduction/extraction and mesh insertion, as well as any additional retraction during the procedure.
Prior to robot docking, the patient is placed in the Trendelenburg position. The Da Vinci robot is then docked. In nearly all cases, the dissection is performed with the fenestrated bipolar and scissors. The necessary adhesiolysis is performed and all contents of the hernia sac are reduced into the abdomen [Figure 2]A. The preperitoneal adipose tissue on the side of the abdomen with the parastomal hernia is taken down to allow for good mesh ingrowth, when necessary. The defect and the extent of the mesh needed will then be measured. A minimum of a 5-cm overlap of the mesh will be required, but in most cases, a larger overlap laterally is preferred (e.g. 8 cm). The enlarged fascial stomal defect will then be partially closed with a #2 barbed polypropylene suture (Ethicon Inc., Somerville, NJ, USA) [Figure 2]B. When a midline ventral hernia defect is encountered, the mesh is sized to encompass all hernia defects with a single mesh. Occasionally, a second mesh will be required.
We initially used a Gore BIO-A (W. L. Gore and Associates, Newark, DE, USA) mesh “keyhole” on the stoma to mimic the prior laparoscopic repair. This was then covered by a DualMesh PLUS (W. L. Gore and Associates) outer layer as a Sugarbaker repair. During this robotic development, we have switched to the Synecor IP (W. L. Gore and Associates). The middle of these meshes was marked to identify the axes of the product for proper positioning. Two purple Vicryl (Ethicon Inc.) sutures are placed at the lateral margin 10 cm apart to help position the mesh to create a tube [Figure 3]A. Through experience, this distance is critical to the proper functioning of the ostomy as smaller distances can result in obstruction. An additional undyed single Vicryl (Ethicon Inc.) suture is then placed in the middle at the other end. The mesh is introduced into the abdomen after it has been soaked in an antibiotic solution composed of 600 mg of gentamicin and 900 mg of clindamycin. The mesh is positioned onto the abdominal wall using those sutures and tailored to the lateralized colon to create a tube to allow egress of the colon in the standard Sugarbaker technique. The two lateral sutures should be placed approximately 2–3 cm apart as they are pulled through the abdominal wall to allow for the appropriate shape of the tube through which the intestine passes. A 2-0 Stratafix polypropylene suture (Ethicon Inc.) is sewn circumferentially to fixate the peripheral edge of the mesh [Figure 3]B and C]. Two separate sutures are used, one on either side of the intestine. A 2 PDO Stratafix (Ethicon Inc., Somerville, NJ) suture is then used to obliterate the space between the edge of the mesh and at the mesocolon [Figure 4]. At that point, the entire area is inspected for any issues and the robot is undocked [Figure 5]. The trocars are removed and the skin incisions are closed with absorbable suture.
|Figure 3: A: Tubularized mesh around colon. Red dots mark the location of transfascial sutures. B: Robotic suturing of mesh in place. C: Direction of robotic suturing with barbed suture|
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|Figure 5: Final fixated mesh with lateralized colon and complete coverage of the hernia defect|
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| Results|| |
There were 24 patients included in the study (nine male, 15 female). The average age was 69.7 years (41–92 years old), and average BMI was 29.25 kg/m2. Of this group, nine patients were former smokers, eight had never smoked, and seven were current smokers who were made to quit 1 month before the procedure. Primary cases resulting in parastomal hernia included ileostomy (n = 7), colostomy (n = 16), and urostomy (n = 1). Significant adhesions were encountered in 15 patients and required lysis of greater than 60 min. Concomitant ventral hernias were encountered in 14 patients [Table 1].
Our primary endpoints were total operative time, console time, and length of stay. The average total operative time was 194.8 min (95–378 min). The console time (from dock to undock) was 149.5 min (72–319 min). The difference in average operative time from the first 12 patients to the last 12 patients was 27.5 min, whereas the average console time difference was 9.6 min. None of the patients required conversion to either a laparoscopic or an open procedure. Overall, the average length of stay was 3.9 days (range: 2–9 days).
Our two most significant complications required a return to the operating room. The first was a diagnostic laparoscopy in the immediate postoperative period to divide an anchoring suture securing the mesh to the abdominal wall that was impinging on the colon causing a large bowel obstruction. The second was the remote development of a hernia between a prior incisional hernia repair mesh and their parastomal hernia mesh requiring reoperation during a separate admission. These repairs occurred during separate operations. One patient was readmitted with a postoperative ileus. Eight patients (33%) developed minor complications, including skin rash, hyponatremia, urinary retention, and postoperative atrial fibrillation. Four additional patients (16%) developed a postoperative seroma that did not require reoperation.
Throughout this process, our outcomes have been acceptable and any complications minor. In the early stages of our experience with the technique, only two patients required reoperation in the immediate postoperative setting as mentioned earlier. Our first patient requiring return to the operating room for a transfascial suture causing colonic impingement. This was very early in our experience due to the fact that the suture was too tightly placed. We were successful with diagnostic laparoscopy to cut the offending suture and the patient recovered uneventfully. Another patient developed an intestinal incarceration between two overlapping pieces of mesh used to fix the parastomal hernia and a prior incisional hernia. There were several minor complications that were managed nonoperatively. These were usually urinary retention. One patient developed pneumonia that was treated with oral antibiotics. Two patients developed atrial fibrillation with rapid ventricular response in the immediate postop period.
| Discussion|| |
A case series of robotic assistant parastomal hernia repair from a single surgeon has been described using a modified Sugarbaker technique. To our knowledge, this is the largest, single surgeon case series of robotic parastomal hernia repairs reported. Most importantly, our patient population is representative of the typical population that develop parastomal hernias. This method can be used to repair ileostomy site hernias as well as colostomy hernia site appears to present improved methods to technical issues with laparoscopy that can be overcome with a robotic platform, such as optimal visualization and wristed instruments. Our results show that this is a reproducible method of repair that is safe and effective without need for conversion. Apart from the two events requiring reoperation, all other adverse outcomes were not uncommon to other hernia repairs. The development of a postoperative seroma is a well-known outcome but not one of our patients required treatment for this outcome.
Sugarbaker first described his open repair technique of a parastomal hernia with a mesh through an open laparotomy in 1985. There usually involves an extensive lysis of adhesions and lateralization of the hollow viscera, partial closure of the defect, and placement of hernia mesh to exclude any other abdominal contents. As minimally invasive techniques and laparoscopy became much more commonplace, this was done intracorporeally. Using trocars for visceral manipulation and introduction of mesh with a completely intracorporeal fixation has several benefits that are well described in the incisional hernia literature. These include a decreased length of stay, reduced pain and discomfort, decreased incision size, and faster recovery time and return to normal activities. However, these repairs are technically very challenging laparoscopically.
The parastomal hernia repair procedure is a physically demanding and time-consuming operation when undertaken laparoscopically. It requires meticulous dissection, gentle handling of the tissue, and precise fixation of the mesh. The laparoscopic approach usually requires a second surgeon assisting to expose and retract while the primary surgeon is dissecting or fixating the mesh. When the Da Vinci Si Robotic Platform was introduced in 2009, it presented an alternative approach to minimally invasive surgery. Prior to this introduction, all minimally invasive repairs of parastomal hernia repairs were purely laparoscopic. We first reported our experience in 2002. Since that time, we have modified our technique.
As the robotic platform was more frequently adopted and our comfort level of operative intervention increased, this was employed by our surgeons and adapted to procedures that were previously undertaken laparoscopically. In our experience, the increased visualization of the robotic platform allowed us to more efficiently, effectively, and safely lyse adhesions compared to conventional laparoscopy. The console interface is ergonomic, which allows for finer control for precise adhesiolysis and delicate intraoperative manipulation of tissues. The ergonomics associated with operating at the robotic console results in less surgeon strain and fatigue throughout the course of long protracted procedures.
As our comfort level with robotic surgery has increased, our robotic technique has also had to undergo significant revision due to the three generations of the robot platforms since we first started. We currently used a Da Vinci Xi robotic system; however, our first hernia case was done in 2014 utilizing the Da Vinci Si system. These advantages have also allowed us to more easily fix a concomitant ventral hernia repair (which was present in over half of our patients). A second ventral defect is usually present after these multiple revision operations. All abdominal wall defects are fixed concomitantly with the available mesh or a single large piece of mesh from our primary hernia repair that is trimmed to fit the other defects.
As we began to get more proficient with our robotic processes, we also reduced our total operative time by 14.1% and console time by 6.4% from our first 12 patients to our last 12 patients. The total change in operative time is most likely attributed to the surgical team more efficiently using the robotic systems. The operating room personnel became more adept with the robotic surgical equipment, quicker more efficient instrument changing, shorter docking and undocking procedure times and overcoming that learning curve. The smaller change in console time is most likely surgeon dependent.
Our mesh selection has also changed as newer technologies became available. Initially, we had used a DualMesh PLUS with BIO-A reinforcement but now have switched to a single Synecor IP mesh that has allowed us to repair all defects with a single mesh. This change was made as that newer hybrid mesh material encompassed the benefits of an absorbable barrier product and the permanent material to protect the hernia repair in the future.
These results present an opportunity for further research in robotic minimally invasive techniques of parastomal hernia repair. The current length of follow-up does not allow for a definitive comment on the rate of recurrence; however, no patient has developed a recurrence to date. Moreover, despite our change in mesh, our clinical results have remained consistent. Surveillance of this population will continue, and we anticipate reporting longer term results in the future. It is hoped that other authors will continue to report on their findings as well, so a true validation of this method can be made.
| Conclusions|| |
Parastomal hernia remains a complex surgical problem and innovative techniques are needed as new technology becomes available. The approach presented allowed us to stay minimally invasive, has few complications, and has similar length of stay to purely laparoscopic approaches. Further research and evaluation are needed to examine long-term follow-up as well as complications. Regardless, adaptability to this new technology and continued innovation are required for the surgeon-in-training as well as the seasoned surgeon.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Kyle M Schmitt,
856 West Nelson Street, Unit 301, Chicago, IL 60657
Source of Support: None, Conflict of Interest: None
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