Prospective randomized controlled trial on comparison of standard CO2 pressure pneumoperitoneum insufflator versus AirSeal®.

BACKGROUND: AirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO2 insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO2 insufflators in patients undergoing the most frequently performed laparoscopic procedures. METHODS: One hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO2 insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien-Dindo grade complications, surgical side effect and length of hospital stay. RESULTS: Patients were randomized to either group A (n = 101) or group S (n = 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56-94] in group A vs. 69 min [52-93] in group S; p = 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0-3] in group S vs. 2 [0-4] in group A; p = 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay. CONCLUSION: This randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO2 insufflator for short elective surgeries. ClinicalTrials.gov (NCT01740011).

[Preperitoneal Umbilical Hernia Mesh Plasty (PUMP): Indications, Technique and Results]. / Präperitoneale umbilikale Netzplastik (PUMP): Indikationen, Technik und Resultate.

BACKGROUND: The principle of the preperitoneal umbilical mesh plasty (PUMP) technique is placement of the prosthesis in the extraperitoneal space, posterior to the rectus muscles, followed by ventral fascia closure. Difficulties can arise from preperitoneal dissection, mesh insertion, deployment, and positioning. METHODS: 81 elective patients underwent preperitoneal repair of primary umbilical or epigastric hernias sized from 2 - 4 cm between January 2015 and March 2018 and were prospectively collected in the Herniamed database and retrospectively analysed. The same general technique was applied, but over time three different types of mesh devices were used. The experience from these cases and the gradual change between the implants during the observation period is described in this study. RESULTS: No intraoperative complications were recorded. Postoperative complications occurred in 6 of 81 patients (7.4%) with the need for unplanned re-operation in 3 cases. Seventy-six of 81 patients (93.8%) attended the one year follow-up evaluation. Three of 76 patients (3.9%) suffered recurrence and five patients (6.6%) requires treatment for chronic pain. CONCLUSION: Surgeons must work with the implant that best suits their patients' needs and that also provides good results and adequate working comfort. The PUMP technique performs well for ventral hernias sized between 2 and 4 cm without the need of midline reconstruction due to diastasis of the rectus muscles. It enables a local extraperitoneal mesh augmentation without the risk of intraperitoneal complications. PUMP repair lowers the risk of recurrence in comparison with suture repair without increasing the risk of complications.

Parastomal Hernia Repair with a 3D Funnel Intraperitoneal Mesh Device and Same-Sided Stoma Relocation: Results of 56 Cases.

BACKGROUND: Parastomal hernias (PSHs) are a common and challenging issue. In previous studies, three-dimensional (3D) funnel mesh devices have been used successfully for the repair of PSHs. METHODS: We performed an analysis of prospectively collected data of patients who underwent a same-sided stoma reposition with 3D funnel-shaped mesh augmentation in intraperitoneal (IPOM) position at our department between the years of 2012 and 2015. Primary outcome parameters were intra- and postoperative surgical complications and recurrence rate during the follow-up period. RESULTS: Fifty-six patients could be included in this analysis. PSH repair was performed in 89.3% as elective surgery and in 73% in laparoscopic technique. A concomitant incisional hernia (EHS type 2 and 4) was found in 50% and repaired in a single-step procedure with PSH. Major postoperative complications requiring redo surgery (Clavien-Dindo ≥3b) were identified in 8.9% (5/56). Overall recurrence rate was 12.5% (7/56). Median follow-up time was 38 months, and a 1-year follow-up rate of 96.4% was reached. CONCLUSION: PSH repair with 3D funnel mesh in IPOM technique is safe, efficient and easy to perform in laparoscopic and open surgical approaches providing advantageous results compared to other techniques. Furthermore, simultaneous detection and treatment of concomitant incisional hernias has shown favorable. However, the mesh funnel distends and becomes shortened encasing a bulky bowel mesentery and further shrinkage happens eccentric. Changing mesh construction according to lengthening the funnel could possibly lead to reduction in recurrence.

Self-Gripping Meshes for Lichtenstein Repair. Do We Need Additional Suture Fixation?

BACKGROUND: The Lichtenstein repair is a frequently used treatment of inguinal hernias. In recent years, there has been an increasing tendency to apply self-gripping meshes (s.g). In many cases, additional suture of the mesh is carried out; however, it is uncertain what the benefits or potential risks of this actually are. METHODS: The evaluation was undertaken on the basis of the Herniamed register, and covered all unilateral Lichtenstein operations between 01.09.2009 up to 30.09.2013. The analysis only included patients with whom s.g. meshes with resorbable micro hooks had been used (Progrip(®), Covidien) and who had undergone a full 1-year follow-up examination (80.15 %). RESULTS: In total, 2095 patients were suitable for analysis, of which 816 (38.95 %) cases received an additional suture fixation (Fix). With increasing hernia size, more frequent fixation took place (29.97 % of hernias <1.5 cm vs. 46.65 % of hernias >3 cm, p < 0.001). The recurrence rates 1 year after surgery did not show any significant differences (Fix. 0.86 % vs. No Fix. 1.17 %; p = 0.661) with and without fixation, even when being adjusted for covariables. Likewise, no differences were noted in terms of postoperative complications (Fix. 5.15 % vs. No Fix. 5.08 %; p = 1.0). In addition, the numbers of patients needing to be treated after 1 year for chronic pain were also comparable (Fix. 2.33 % vs. No Fix. 2.97 %; p = 0.411). CONCLUSION: Within the group that did not have additional suture fixation of self-gripping meshes (No Fix.), the length of operations was on average 8 min shorter (p < 0.001). No differences could be observed in terms of postoperative complications, treatment requiring chronic pain and recurrence rates.

Obesity does not affect the outcome of laparoscopic antireflux surgery.

BACKGROUND: Obesity has been reported to adversely affect the outcome of laparoscopic antireflux surgery (LARS). This study examined pre- and postoperative clinical and objective outcomes and quality of life in obese and normal-weight patients following LARS at a specialized centre. METHODS: Prospective data from patients subjected to LARS (Nissen or Toupet fundoplication) for symptomatic gastroesophageal reflux disease in the General Public Hospital of Zell am See were analyzed. Patients were divided in two groups: normal weight [body mass index (BMI) 20-25 kg/m(2)] and obese (BMI ≥ 30 kg/m(2)). Gastrointestinal quality of life index (GIQLI), symptom grading, esophageal manometry and multichannel intraluminal impedance monitoring data were documented and compared preoperatively and at 1 year postoperatively. RESULT: The study cohort included forty normal-weight and forty obese patients. Mean follow-up was 14.7 ± 2.4 months. The mean GIQLI improved significantly after surgery in both groups (p < 0.001, for both). Clinical outcomes improved following surgery regardless of BMI. There were significant improvements of typical and atypical reflux symptoms in normal weight and obese (p = 0.007; p = 0.006, respectively), but no difference in gas bloat and bowel dysfunction symptoms could be found. No intra- or perioperative complications occurred. A total of six patients had to be reoperated (7.5 %), two (5 %) in the obese group and four (10 %) in the normal-weight group, because of recurrent hiatal hernia and slipping of the wrap or persistent dysphagia due to closure of the wrap. CONCLUSION: Obesity is not associated with a poorer clinical and objective outcome after LARS. Increased BMI seems not to be a risk factor for recurrent symptomatology and reoperation.

Comparison of 231 patients receiving either "pull-through" or "push" percutaneous endoscopic gastrostomy.

BACKGROUND: A percutaneous endoscopic gastrostomy (PEG) can be performed as a direct stomach puncture, known as Seldinger technique ("push") or a thread pulling method ("pull"). The aim of this study was to compare the final results deriving from both application methods. METHODS: Data of all pull-through-PEG and push-PEG applications, which had been carried out in our department from 2009 to 2012, were analyzed and compared retrospectively. Data collection included patients' demographics, indications, comorbidities, peri-interventional chemotherapy, and/or radiotherapy. The complications were graded according to the Clavien-Dindo classification and divided in early- and late-term complications (before and after 10 days after PEG insertion). RESULTS: A total of 231 patients received a PEG. Of these, 131 (56.7 %) were treated with pull-through-PEGs and 100 (43.3 %) with the push-PEG method. Overall, in 61 of 231 (26.4 %) patients, a complication was documented and 37 of 61 (60.6 %) were assigned to Clavien-Dindo grade 1. Only 5 of 231 patients (2.2 %) required a re-intervention or surgical treatment under general anesthesia. The overall complication rate was significantly increased by the type of push-PEG tube used (push 33/100 = 33 vs. pull 28/131 = 21.4 %, p = 0.047). A dislocation of the tube was noticed in 5/131 (3.8 %) cases of pull-PEGs and 12/100 (12 %) cases of push PEGs (p = 0.018). An occlusion of the PEG also occurred significantly more frequent in connection with the push-PEG (10/100 = 10 vs. 1/131 = 0.8 %; p < 0.001). CONCLUSION: Both PEG techniques are safe and well established. Push PEG showed a significantly higher rate of overall complications, dislocations, and occlusions. The decision which PEG tube should be used depends on individual conditions with preference of push-PEGs in patients with head, neck, and esophageal cancer.

Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus diastasis is a significant risk factor for recurrence.

BACKGROUND: Umbilical and epigastric hernias are common in the adult population and prompt repair is advised. We aimed to evaluate the impact of concomitant rectus diastasis on the outcome of patients who underwent primary sutured fascia closure of a hernia without mesh. METHODS: We performed a retrospective analysis of 231 consecutive adult patients who had undergone elective suture-based repair of small (<2 cm) and primary umbilical or epigastric hernias with respect to complications, recurrence, and chronic pain. RESULTS: Patients with rectus diastasis suffered from a significantly increased rate of hernia recurrence (29/93 vs. 9/108; p < 0.001). The use of absorbable sutures also had a negative influence on the recurrence rate (26/90 vs. 12/111; p = 0.001). Obesity (body mass index > 35 kg/m(2)) was associated with more complications (p = 0.02). Wound infections following hernia repair also were associated with a higher rate of recurrence (p = 0.08) and chronic pain (p = 0.02). The mean follow-up via a structured questionnaire was 31 months (range 3-59) and data were available for 201 of 231 patients (87 %). CONCLUSION: We strongly recommend preoperatively checking for rectus diastasis and using nonabsorbable sutures as an alternative to mesh repair only when repairing small umbilical or epigastric hernias (<2 cm) and there is no concomitant rectus diastasis. Patients with coexistent rectus diastasis definitely benefit from mesh-based repair of the midline to decrease the recurrence rate.

Changes in the Surgical Management of Parastomal Hernias Over 15 Years: Results of 135 Cases.

BACKGROUND: Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures. METHODS: From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences. RESULTS: One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12-146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured. CONCLUSION: The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p < 0.001).

Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications.

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

A systematic review and analysis of factors associated with methodological quality in laparoscopic randomized controlled trials.

Several methods for assessment of methodological quality in randomized controlled trials (RCTs) have been developed during the past few years. Factors associated with quality in laparoscopic surgery have not been defined till date. The aim of this study was to investigate the relationship between bibliometric and the methodological quality of laparoscopic RCTs. The PubMed search engine was queried to identify RCTs on minimally invasive surgery published in 2012 in the 10 highest impact factor surgery journals and the 5 highest impact factor laparoscopic journals. Eligible studies were blindly assessed by two independent investigators using the Scottish Intercollegiate Guidelines Network (SIGN) tool for RCTs. Univariate and multivariate analyses were performed to identify potential associations with methodological quality. A total of 114 relevant RCTs were identified. More than half of the trials were of high or acceptable quality. Half of the reports provided information on comparative demo graphic data and only 21% performed intention-to-treat analysis. RCTs with sample size of at least 60 patients presented higher methodological quality (p = 0.025). Upon multiple regression, reporting on preoperative care and the experience level of surgeons were independent factors of quality.

Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis.

PURPOSE: Laparoscopic repair of large hiatal hernias is associated with high recurrence rates. Erosion and mesh migration are rare but devastating complications of synthetic mesh repair, whereas reoperation is accompanied by significant operative morbidity. The aim of this study was to estimate the comparative risk of hernia recurrence following primary suture or biologic mesh repair. METHODS: A systematic literature search of the MEDLINE database was performed and comparative data of relevant studies were combined using the Mantel-Haenszel meta-analysis model. The odds ratio (OR) for hernia recurrence with 95 % confidence interval (CI) was calculated. RESULTS: Five relevant studies (two randomized controlled trials and three case-control studies) and one follow-up report of a randomized trial, encompassing 295 patients, were identified. Small intestine submucosa and human acellular cadaveric dermis were used as mesh grafts. Short-term recurrence rates were 16.6 and 3.5 % for suture repair and biologic mesh repair, respectively (OR 3.74, 95 % CI 1.55-8.98, p = 0.003). Long-term recurrence based on data provided by one trial only was 51.3 and 42.4 %, respectively (OR 1.43, 95 % CI 0.56-3.63, p = 0.45). Sensitivity analysis of the two randomized trials at short-term follow up demonstrated no significant difference (OR 2.54, 95 % CI 0.92-7.02, p = 0.07). CONCLUSIONS: Biologic mesh repair of large hiatal hernias may confer short-term benefits in terms of hernia recurrence; however, the limited available information does not allow us to make conclusions about the long-term efficacy of biologic mesh in this setting. Individual biologic mesh grafts require further clinical assessment.

Prevention of subcutaneous seroma formation in open ventral hernia repair using a new low-thrombin fibrin sealant.

BACKGROUND: Seroma formation is a frequent postoperative complication following open ventral hernia repair (OVHR), especially in cases requiring wide subcutaneous dissection (WSD). The aim of this study was to evaluate the effectiveness of a new low-thrombin fibrin sealant for seroma prevention. METHODS: A total of 60 consecutive patients with median incisional hernias who required OVHR with WSD of at least 100 cm(2) were included in the prospective non-randomized study. The fibrin glue group (FG) comprised 30 patients who had undergone OVHR with sublay mesh placement as well as subcutaneous application of low-thrombin fibrin sealant. This cohort of patients was compared with a control group (CG) of 30 consecutive patients who had previously undergone OVHR without prevention of seroma formation with regard to outcome measures such as seroma formations and wound complications. RESULTS: Though the median extent of subcutaneous dead space was larger in the FG than in the CG (229 vs.174 cm(2); p = 0.012), seroma formation occurred in three of the FG versus 16 of the CG patients (p = 0.003). Postoperative wound complications occurred in two of the FG versus nine of the CG patients (p = 0.002). Four patients in the CG and none in the FG required re-operation within 30 days (p < 0.001). CONCLUSION: The use of a new low-thrombin fibrin glue demonstrated a protective effect against formation of seromas and decreased the rate of wound complications in OVHR, with consecutive shorter length of hospital stay (5.8 vs. 10.4 days; p = 0.04).

Relevance of surgery after embolization of gastrointestinal and abdominal hemorrhage.

BACKGROUND: Gastrointestinal and abdominal bleeding can lead to life-threatening situations. Embolization is considered a feasible and safe treatment option. The relevance of surgery has thus diminished in the past. The aim of the present study was to evaluate the role of surgery in the management of patients after embolization. METHODS: We performed a retrospective single-center analysis of outcomes after transarterial embolization of acute abdominal and gastrointestinal hemorrhage between January 2009 and December 2012 at the Sisters of Charity Hospital, Linz. Patients were divided into three groups, as follows: upper gastrointestinal bleeding (UGIB), lower gastrointestinal bleeding (LGIB), and abdominal hemorrhage. RESULTS: Fifty-four patients with 55 bleeding events were included. The bleeding source could be localized angiographically in 80 %, and the primary clinical success rate of embolization was 81.8 % (45/55 cases). Early recurrent bleeding (<30 days) occurred in 18.2 % (10/55) of the patients, and delayed recurrent hemorrhage (>30 days) developed in 3.6 % (2/55). The mean follow-up was 8.4 months, and data were available for 85.2 % (46/54) of the patients. Surgery after embolization was required in 20.4 % of these patients (11/54). Failure to localize the bleeding site was identified as predictive of recurrent bleeding (p = 0.009). More than one embolization effort increased the risk of complications (p = 0.02) and rebleeding (p = 0.07). CONCLUSIONS: Surgery still has an important role after embolization in patients with gastrointestinal and abdominal hemorrhage. One of five patients required surgery in cases of early and delayed rebleeding or because of ischemic complications (2/55 both had ischemic damage of the gallbladder) and bleeding consequences.

Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease.

BACKGROUND: Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect. METHODS: The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1-4 using Hill's classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05. RESULTS: A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly. CONCLUSIONS: The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.

[Management of lateral abdominal wall hernias]. / Management der lateralen Bauchwandhernien.

Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the European Hernia Society classification makes sense, not least for the purpose of comparing the quality of surgical results. A distinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally a low level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make the technical treatment of lateral hernias difficult. The surgical variations include laparoendoscopic, robotic, minimally invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transabdominal peritoneal (TAPP) laparoscopic repair or total extraperitoneal (TEP) endoscopic repair has met with the greatest approval. The extent of the required medial mesh overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus abdominus muscles. The medially directed preperitoneal and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The intraperitoneal onlay mesh (IPOM) technique is a suitable procedure only for smaller defects with possible defect closure but it is also important as an exit strategy in the case of a defective peritoneum. Individualized prehabilitative and preconditioning measures are just as important as the assessment of preoperative anamnestic and clinical findings and risks with radiographic cross-sectional imaging diagnostics.

Robotic hernia surgery IV. English version : Robotic parastomal hernia repair. Video report and preliminary results.

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

[Robotic hernia surgery IV. German version : Robotic parastomal hernia repair. Video report and preliminary results]. / Robotische Hernienchirurgie Teil IV : Roboterassistierte endoskopische parastomale Hernienversorgung. Videobericht und Ergebnisse.

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

A Novel Technique for Parastomal Hernia Repair Combining a Laparoscopic and Ostomy-Opening Approach.

INTRODUCTION: The aim of this study was to evaluate a new method of parastomal hernia (PSH) repair by using a hybrid approach with a cylindrical-shaped mesh of 4 cm funnel length. MATERIALS AND METHODS: In a pilot prospective case series, 12 patients underwent surgical repair of PSHs with a combined laparoscopic and ostomy-opening approach. After laparoscopic adhesiolysis, the ostomy opening was excised from outside and the bowel was closed. The hernia sac was excised after reduction of its content. Then, the bowel was guided through the funnel of the mesh and the implant was manually transferred into the peritoneal cavity through the hernia defect. Next, the fascial margins were narrowed with sutures. Laparoscopy was continued, and the mesh was placed and fixed with absorbable tacks in the proper position. Finally, the diverted bowel was shortened outside of the abdomen and the stoma was matured in its original location. RESULTS: We documented no mesh-associated complications. Only one superficial peristomal wound defect occurred. No unplanned conversions were needed, and median duration of the operations was 72 minutes. There was no recurrence during the short-term follow-up of median 4 months (ranged from 3 to 8 months). DISCUSSION: The technique described gives several advantages, such as a minimally invasive hybrid approach creating a real three-dimensional mesh-covered barrier between the trephine and stomal limb and optional shortening of a concomitant prolapse. When needed due to a concomitant incisional hernia, a second flat mesh can be laparoscopically placed in an intraperitoneal position.