Dear All,
I have a 60 year old male. He has had radical cystectomy, nephrectomy on the right and an urostoma constructed with an ileum conduit in his left lower abdomen. He was operated in 2/2014 due to a first recurrence of this parastomal hernia with a sublay-mesh. Then he developed a subcutaneous urinoma 2 days later and needed revisional surgery. the mesh needed to be removed, the hernia was closed with direct closure without a new mesh. After a few weeks he was developing a new parastomal hernia, as expected and presented in my outpatient clinic.
He need repair of his parastomal hernia, because its painful and disturbs in daily life.
The question is: which approach should we take? I think that direct approach from outside trying to fix the hernia with another mesh in sublay position will be difficult, because i'm expecting adhesions in the subfascial plane and large dissection will be needed. We decided for performing a transabdominal approach, with adhesiolysis and direct closure of the hernia including a IPOM mesh support (DynaMesh).
Any suggestions? Henry.
We have had a substantial experience with laparoscopic parastomal hernia, initially using a keyhole mesh, which closed the defect but there was a tendency for the bowel to slide through the keyhole defect in the mesh giving the appearances of recurrence even though the defect was closed. Some years ago we switched to a laparoscopic modified Sugarbaker technique, which has proved very successful. This utilises a large 15x 15 or 20x20cm flat mesh laid over the defect and forming a tunnel for the bowel to be held against the abdominal wall.
Thank you very much for this answer. But i think that Sugarbaker technique may not be suitable for a parastomal hernia of an ileum conduit. What do you think?
I guess it depends whether it proves to be long enough to lie back against the abdominal wall. If it will then I think it would be fine.
Exactly, we have to separate all adhesions and will see, how floppy the ileum-conduits looks like. Then we may either go for Sugarbaker-procedure or circular mesh repair.
our experience is to do lap adhesiolysis,reduction of Hernia,narrowing of the defect and fix a circular mesh split on one side to silde it around the ileum and tack it to the peritoneum.
Dear All,
we just did the procedure successfully.
Due to several previous abdominal operations, it was performed in an open manner. We needed to do adhesiolysis, but shortly we could explore the hernia. We reduces the hernia, nerrowed the hernia with non-absorbable sutures, and tailored a Parietex-mesh (IPST) around the Ileum-conduit.
The postoperative course was unevenful. Patient was dicharged 6 days after the Operation.
Just saw the patient 2 weeks post-OP.
He is doing well. Due to the inability to resect the complete hernia sac from inside, he developed a subcutaneous seroma. We will wait until it has resolved. beside that he is doing great and back to his normal life activity.
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