Repair of Parastomal Hernias.

Parastomal hernias are an inevitable consequence of ostomy formation and their repairs remain a challenge to many surgeons. With multiple systems of classification and a multitude of techniques for hernia repair ranging from suture to mesh repair, the literature remains sparse with regards to the optimal method of repair. The authors describe the most commonly adopted techniques, discuss preventative measures, and review the current literature in the context of perioperative outcomes and hernia recurrence.

Incidence and risk factors for perineal hernia after robotic abdominoperineal resection: a single-center, retrospective cohort study.

BACKGROUND: Perineal hernia (PH) is a late complication of abdominoperineal resection (APR) that may compromise a patient's quality of life. The frequency and risk factors for PH after robotic APR adopting recent rectal cancer treatment strategies remain unclear. METHODS: Patients who underwent robotic APR for rectal cancer between December 2011 and June 2022 were retrospectively examined. From July 2020, pelvic reinforcement procedures, such as robotic closure of the pelvic peritoneum and levator ani muscles, were performed as prophylactic procedures for PH whenever feasible. PH was diagnosed in patients with or without symptoms using computed tomography 1 year after surgery. We examined the frequency of PH, compared characteristics between patients with PH (PH+) and without PH (PH-), and identified risk factors for PH. RESULTS: We evaluated 142 patients, including 53 PH+ (37.3%) and 89 PH- (62.6%). PH+ had a significantly higher rate of preoperative chemoradiotherapy (26.4% versus 10.1%, p = 0.017) and a significantly lower rate of undergoing pelvic reinforcement procedures (1.9% versus 14.0%, p = 0.017). PH+ had a lower rate of lateral lymph node dissection (47.2% versus 61.8%, p = 0.115) and a shorter operative time (340 min versus 394 min, p = 0.110). According to multivariate analysis, the independent risk factors for PH were preoperative chemoradiotherapy, not undergoing lateral lymph node dissection, and not undergoing a pelvic reinforcement procedure. CONCLUSIONS: PH after robotic APR for rectal cancer is not a rare complication under the recent treatment strategies for rectal cancer, and performing prophylactic procedures for PH should be considered.

Prophylactic surgical mesh placement as a prevention of parastomal hernia in open radical cystectomy with ileal conduit diversion - pilot study.

INTRODUCTION: This study examines the efficacy of prophylactic mesh implantation during open radical cystectomy with ileal conduit diversion in preventing parastomal hernias (PH). Despite PH being a common complication, prophylactic methods have been underexplored. METHODS: A pilot, single-center, prospective cohort study was conducted involving five patients undergoing surgery with mesh implantation. Demographic and clinical characteristics were monitored, including the incidence of PH, operation time, blood loss, and hospitalization duration. RESULTS: During the mean follow-up period of 9.1±3.2 months post-operation, no occurrences of PH were observed in the patient group. Despite the risks associated with implanting foreign material in an area of surgery involving open small intestine, no infectious complications were noted. CONCLUSION: Prophylactic mesh implantation in radical cystectomy with ileal conduit diversion appears to be an effective preventive measure against PH. Further extensive studies are required to definitively confirm the efficacy and safety of mesh use in this context.

Parietal complications after cystectomy: Incisional and parastomal hernia, epidemiology and risk factors.

INTRODUCTION: Incisional and parastomal hernias are frequent complications after cystectomy. The aim of our study was to define their incidence, identify risk factors related to the patient and the surgical technique, and identify means of prevention. MATERIAL: This was a multicenter, retrospective study, analyzing clinical and radiological data from 521 patients operated on for cystectomy between January 2010 and December 2020. RESULTS: In total, 521 patients, 471 men and 50 women, mean age 68.8years, were included. Thirty-one patients (6.6%) presented with an evisceration. Risk factors were a history of evisceration (OR: 14.1; 95% CI: [3-66]; P=0.0008), COPD (OR: 3.5; 95% CI: [1.3-9 .4]; P=0.0119), ischemic heart disease (OR: 4; 95% CI: [1. 6-10]; P=0.0036), and split-stitch closure (OR: 3.1; 95% CI: [1.065-8.9]; P=0.0493). Fifty-one patients (9.9%) presented with an incisional hernia. Risk factors were a history of COPD (OR: 4, 95% CI: [2.1-7.6]; P<0.001) and postoperative pulmonary infection (OR: 5.3; 95% CI: [1.05-26.4]; P=0.0079). Seventy-nine patients (15.28%) had a parastomal hernia. Overweight was a risk factor (OR: 2.3; 95% CI: [1.3-4.5]; P=0.0073). CONCLUSION: Patients who are overweight or have pulmonary comorbidities are at greater risk of developing parietal complications after cystectomy. LEVEL OF EVIDENCE: III.

Effects of different mesh materials on complications after prophylactic placement for stoma formation: a systematic review and network meta-analysis.

PURPOSE: We primary aimed to synthesise the available data, assess the effectiveness of different mesh materials in prophylactic mesh placement, and rank these materials according to the incidence of parastomal hernia (PSH) and other stoma complications. METHOD: This network meta-analysis performed a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Four databases were searched for randomised controlled trials of prophylactic mesh placement. The aggregated results were performed in the STATA routine for Bayesian hierarchical random effects models. RESULT: Thirteen randomised controlled trials from 1203 articles, met the inclusion criteria, including 681 cases without meshes, 65 cases with mesh material of xenogeneic acellular dermis (porcine/bovine), 27 cases with polypropylene/PG910, 114 cases with polypropylene/polyglecaprone (Monocryl), 117 cases with polypropylene/cellulose (ORC), 233 cases with polypropylene, and 35 cases with polypropylene/PVDF. In network A, compared with no mesh, only polypropylene (RR 0.24, 95% CI 0.04-0.80) were significantly associated with a reduction in the incidence of PSH. In network B, no statistical difference regarding stoma complications was found between mesh and no mesh. CONCLUSION: Based on the network meta-analysis and ranking results, the polypropylene mesh material exhibited the best performance. However, this conclusion needs to be confirmed with larger sample sizes and high-quality randomised controlled trials.

Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery.

PURPOSE: To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery. METHODS: We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed. RESULTS: The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access. CONCLUSION: The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Complications associated with loop ileostomy: analysis of risk factors.

BACKGROUND: Loop ileostomy is a common surgical procedure but is associated with complications such as outlet obstruction (OO), parastomal hernia (PH), and high-output stoma (HOS). This study aimed to identify risk factors for these complications, as well as their causal relationships. METHODS: The study included 188 consecutive patients who underwent loop ileostomy between April 2016 and September 2021. Clinical factors and postoperative stoma-related complications (OO, HOS, and PH) were analyzed retrospectively. Stoma-related factors were evaluated using specific measurements from computed tomography (CT) scans. The incidence, clinical course, and risk factors for the stoma-related complications were investigated. RESULTS: OO was diagnosed in 28 cases (15.7%), PH in 60 (32%), and HOS in 57 (31.8%). A small longitudinal stoma diameter at the rectus abdominis level on CT and a right-sided stoma were significantly associated with OO. Creation of an ileostomy for anastomotic leakage was independently associated with HOS. Higher body weight and a large longitudinal stoma diameter at the rectus abdominis level on CT were significantly associated with PH. There was a significant relationship between the occurrence of OO and HOS. However, the association between OO and PH was marginal. CONCLUSION: This study identified key risk factors for OO, HOS, and PH as complications of loop ileostomy and their causal relationships. Our findings provide insights that may guide the prevention and management of complications related to loop ileostomy.

Trocar-site incisional hernia after 8-mm robotic trocar placement: A prospective study.

BACKGROUND: The current literature supports the closure of trocar sites ≥10-mm for the risk of developing incisional hernias, while there is no need to suture the abdominal fascia when using 5-mm trocars. To date, evidence regarding the closure of 8-mm trocars that are use by new robotic systems is weak. The aim of our study was to investigate the incidence of incisional hernia for 8-mm trocars. METHODS: We prospectively collected data on all patients undergoing robotic-assisted abdominal wall surgery from 2020 to 2023, in whom the abdominal fascia of all 8-mm trocars was not closed. The enrolled patients underwent a follow-up visit during which we conducted clinical and sonographic evaluations of all 8-mm trocars, in addition to assessing the satisfaction levels of the patients. The primary outcome was the incidence of port-site hernia. RESULTS: We enrolled 166 patients, 155 men and 11 women, for a total of 513 trocars accessed. Mean age was 61.1 ± 14.0 years, and mean BMI was 27.0 ± 3.9 kg/m2. The follow-up visits were carried out after a median follow-up of 14.5 (9.0-23.2) months. Only one case developed an asymptomatic 1 × 1 cm supra-umbilical hernia that was not treated. Patient reported a satisfaction regarding the 8-mm trocars and skin sutures of 9.8 ± 0.5 out of 10 points. CONCLUSIONS: The occurrence of a trocar-site hernia after 8-mm robotic access is extremely low. Hence, the fascia closure may not be necessary.

Incidence of incisional hernia in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: an observational clinical study from a tertiary oncology referral care center in India.

BACKGROUND: An incisional hernia (IH) after major abdominal surgery is an unwanted complication particularly following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC). The frequency of IH among patients treated with CRS and HIPEC remains unexpectedly high in various studies. This study aimed to analyze the incidence, determine the factors contributing to the occurrence of IH, and develop methods to reduce the incidence of IH. METHODS: We retrospectively analyzed data from a prospectively maintained structured computerized comprehensive database of 360 patients who had undergone CRS and HIPEC after January 2013 and completed two years of follow-up before December 2023. All patients were followed for a minimum period of two years with physical examination and radiological imaging when required and the occurrence of IH was documented. We used SPSS software version 24 to analyze the data using appropriate statistical tests. We set a significance threshold of p < 0.05. RESULTS: Within two years of undergoing CRS and HIPEC, 25 patients (6.9%) out of 360 developed IH, indicating an annual incidence rate of 3.5%. The mean duration of hospitalization for the CRS/HIPEC procedure was 8.4 ± 4.13 days. Fifty-two (14.4%) patients experienced early post-operative surgical complications. The development of IH in our series was significantly associated with obesity (76% vs. 8.4%, P = 0.001), the occurrence of early post-operative surgical complications (48% vs. 12%, P = 0.001), mainly category III complications (44% vs. 7.1%), category IV complications (24% vs. 2.9%) according to Clavien-Dindo classification, post neoadjuvant chemotherapy status (72% vs. 87%, P = 0.045) and need for bowel anastomosis (32% vs. 11%, P = 0.002). CONCLUSION: The lower incidence of IH following CRS and HIPEC in our patient cohort than in the literature can be attributed to a combination of factors, including the use of meticulous surgical techniques and the use of an abdominal binder postoperatively, particularly in obese patients.

Superiority trial for the development of an ideal method for the closure of midline abdominal wall incisions to reduce the incidence of wound complications after elective gastroenterological surgery: study protocol for a randomized controlled trial.

BACKGROUND: The recent guidelines from the European and American Hernia Societies recommend a continuous small-bite suturing technique with slowly absorbable sutures for fascial closure of midline abdominal wall incisions to reduce the incidence of wound complications, especially for incisional hernia. However, this is based on low-certainty evidence. We could not find any recommendations for skin closure. The wound closure technique is an important determinant of the risk of wound complications, and a comprehensive approach to prevent wound complications should be developed. METHODS: We propose a single-institute, prospective, randomized, blinded-endpoint trial to assess the superiority of the combination of continuous suturing of the fascia without peritoneal closure and continuous suturing of the subcuticular tissue (study group) over that of interrupted suturing of the fascia together with the peritoneum and interrupted suturing of the subcuticular tissue (control group) for reducing the incidence of midline abdominal wall incision wound complications after elective gastroenterological surgery with a clean-contaminated wound. Permuted-block randomization with an allocation ratio of 1:1 and blocking will be used. We hypothesize that the study group will show a 50% reduction in the incidence of wound complications. The target number of cases is set at 284. The primary outcome is the incidence of wound complications, including incisional surgical site infection, hemorrhage, seroma, wound dehiscence within 30 days after surgery, and incisional hernia at approximately 1 year after surgery. DISCUSSION: This trial will provide initial evidence on the ideal combination of fascial and skin closure for midline abdominal wall incision to reduce the incidence of overall postoperative wound complications after gastroenterological surgery with a clean-contaminated wound. This trial is expected to generate high-quality evidence that supports the current guidelines for the closure of abdominal wall incisions from the European and American Hernia Societies and to contribute to their next updates. TRIAL REGISTRATION: UMIN-CTR UMIN000048442. Registered on 1 August 2022. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000055205.

Risk factors of recurrence after incisional hernia preperitoneal repair: a long-term retrospective single-center cohort study.

PURPOSE: To explore the risk factors for incisional hernia (IH) recurrence following open prepertioneal repair. METHODS: Patients diagnosed with primary IH who underwent open preperitoneal repair at our hospital were enrolled. Patients were assessed, and perioperative factors were collected. Recurrence surveys were performed at regular intervals throughout the long-term postoperative follow-up. The risk factors for IH recurrence were identified using univariate and multivariate analyses. RESULTS: This study included 145 patients. Significant differences were found between recurrence and non-recurrence patients regarding pulmonary ventilation function (PVT), age, body mass index (BMI), mesh materials, type of surgery (clean, clean-contaminated, or contaminated), surgical site infections (SSIs), maximum width of the hernia defect (MWHD), and site of incisional hernia (P < 0.01). The univariate survival analysis revealed that PVT abnormalities, age > 70 years, BMI > 27 kg/m2, porcine small intestine submucosal (PSIS) mesh, non-clean surgery, SSIs, MWHD > 10 cm, and location in the lateral zones were significant factors for IH recurrence after open preperitoneal repair. The multivariate survival analysis showed that PVT abnormalities, age > 70 years, BMI > 27 kg/m2, and PSIS mesh were independent risk factors for IH recurrence after open preperitoneal repair. CONCLUSIONS: We identified PVT abnormalities, age > 70 years, BMI > 27 kg/m2, and PSIS mesh as novel risk factors for IH recurrence after open preperitoneal repair.

Linking factors to incisional hernia following pancreatic surgery: a 14-year retrospective analysis.

BACKGROUND: Incisional hernias (IH) are a significant postoperative complication with profound implications for patient morbidity and healthcare costs. The relationship between IH and perioperative factors in pancreatic surgery, with particular attention to preoperative biliary stents and pancreatic fistulas requires further exploration. METHODS: This retrospective observational study examined adult patients who underwent open pancreatic surgeries via midline incision at a high-volume tertiary hepatopancreatobiliary center from January 2008 to December 2021. The study focused on IH incidence and associated risk factors, with particular attention to preoperative biliary stents and pancreatic fistulas. RESULTS: In a cohort of 620 individuals undergoing pancreatic surgery, 351 had open surgery with at least one-year follow-up. Within a median follow-up of 794 days (IQR 1694-537), the overall incidence of IH was 17.38%. The highest frequency of IH was observed among patients who had a Pancreaticoduodenectomy (PD). Significant predictors for the development of IH within the entire study population in a multivariable analysis included perioperative biliary stenting (OR 2.05; 95% CI 1.06-3.96; p = 0.03), increased age at diagnosis (OR 2.05; 95% CI 1.06-3.96; p = 0.01), and BMI (OR 1.08; 95% CI 1.01-1.15; p = 0.01). In the subset of patients who underwent Pancreaticoduodenectomy (PD), although the presence of biliary stents was associated with a heightened occurrence of SSIs, it did not demonstrate a direct correlation with an increased incidence of incisional hernias (IH). The development of pancreatic fistulas did not show a significant correlation with IH in either the Distal Pancreatectomy with Splenectomy (DPS) or the PD patient groups. CONCLUSIONS: The study underscores a notable association between biliary stent placement and increased IH risk after PD, mediated by elevated SSI incidence. Pancreatic fistulas were not directly correlated with IH in the studied cohorts. Further research is necessary to validate these findings and guide clinical practice.

Parastomal hernia repair according to Modified Stapled Mesh Stoma Reinforcement Technique (mSMART): which are the results ?

INTRODUCTION: Parastomal hernia repair is a real surgical challenge because of the high rate of recurrence. The Stapled Mesh Stoma Reinforcement Technique (SMART) is a keyhole-like technique in which the mesh is stapled to the fascia using a circular mechanical stapler. METHODS: A prospective study from January 2021 to February 2023 was conducted including all patients operated with the SMART technique. Primary endpoint was the recurrence rate during the follow-up. Secondary endpoints were reoperation, Surgical site Occurrence (SSO) and deep (mesh) surgical site infection (SSI) within 30 days postoperatively. RESULTS: Sixteen patients operated on SMART procedures were included. The mean follow-up was 11.3 ± 9.2 months. The SSO rate was 18.7% (n = 3). A seroma was drained radiologically (IIIa), one haematoma was evacuated surgically (IIIb) and one patient presented a postoperative lesion of a ureter after a parastomal Bricker's hernia repair. In addition, there was one death due to multiple organ failure (V). There was no SSI. The recurrence rate was 57.1% during the follow-up. CONCLUSION: This study shows disappointing results for this SMART technique, with a high recurrence rate.

End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches.

INTRODUCTION: Parastomal hernia (PSH) is the most common and challenging complication after stoma creation, with an estimated 50% incidence 2 years after the index surgery. Mesh repair is the treatment of choice. Laparoscopic and/or robotic approaches allow acceptable outcomes. MATERIALS AND METHODS: A systematic literature review from January 2012 to November 2023 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Embase, PubMed, and Scopus search were performed to select articles dealing with minimally invasive surgical treatment for PSH after end colostomy. RESULTS: 603 studies were found, and 24 were chosen. When compared to open surgery, laparoscopy showed decreased postoperative complications and recurrence. The main laparoscopic approaches are the keyhole (KH), the Sugarbaker (SB), and the sandwich technique. Continuous improvement in surgery, mesh technology, and surgeons' expertise led to an amelioration of surgical outcome and recurrence rate after repair. Recent studies showed comparable outcomes for SB and KH techniques, while novel surgical approaches have been proposed in an attempt to further increase the operative and long-term results. Reports on PSH robotic repairs are scarce and describe small series results, suggesting a role of the initial learning curve as a risk factor for complications. CONCLUSION: End-colostomy PSH surgical repair still represents a challenge for surgeons. Recent evidence has not shown a significant advantage in postoperative complications and recurrence with a specific repair among SB, KH, and sandwich technique. The paucity of data on robotic surgery does not allow to draw definitive conclusion. Further primary, multicentric, and larger cohort studies are needed.

Parastomal hernia repair, trying to optimize the impossible reconstruction.

PURPOSE: Parastomal hernias are a common and challenging problem with high rates of wound complications and hernia recurrence after repair. We present our approach to optimizing parastomal hernia repair through preoperative preparation, surgical approach, and postoperative management. METHODS: Patients are carefully evaluated and optimized prior to surgery. Our typical surgical approach involves a generous midline laparotomy and retrorectus dissection followed by a posterior component separation with transversus abdominis release. We typically utilize a Sugarbaker technique for retromuscular mesh placement but also use the retromuscular keyhole or cruciate technique if there is insufficient bowel length. RESULTS: Previously published results from our institution include wound complication rates of up to 16% after open retromuscular parastomal hernia repair. Stoma-specific complications, such as mesh erosion in the bowel, may be attributed to the mesh placement techniques. Hernia recurrence rates range from 11 to 30% up to 2 years postoperatively. CONCLUSION: We prefer an open retromuscular approach with a Sugarbaker mesh configuration to treat complex parastomal hernias. However, wound morbidity and repair failure rates remain high, and additional research is needed to optimize surgical outcomes.

Parastomal hernia prevention with an intraperitoneal prophylactic 3D-funnel mesh: review of the technique and middle-term results.

PURPOSE: Parastomal hernia (PH) stands out as a prevalent complication following end colostomies, significantly affecting patients' quality of life. Various surgical strategies, predominantly involving prophylactic mesh deployment, have been explored with variable outcomes. This study details our experience and mid-term outcomes utilizing a funnel-shaped mesh. METHODS: A single-center, prospective, non-randomized, observational study examined consecutive patients undergoing colorectal surgery with end colostomy, incorporating a 3D-funnel mesh from January 2019 to December 2021 (PM group). A historical cohort of patients with end colostomy without prophylactic mesh served as the comparison (C group). Postoperative morbidity within 30 days was documented, and clinical examinations and radiological tests were employed for parastomal hernia diagnosis during follow-up. RESULTS: Seventy-two patients participated, with thirty-four in the PM group and thirty-eight in the C group. The PM group experienced 16 postoperative complications, unrelated to the mesh, while the C group recorded 20 complications (p = 0.672). Median follow-up was 22.06 months for the PM group and 63.18 months for the C group. The PM group exhibited a lower parastomal hernia incidence during follow-up (8.8%) compared to the C group(68.4%) (p < 0.001). CONCLUSION: Prophylactic use of a 3D-funnel mesh appears effective in reducing parastomal hernia incidence in the short and mid-term, without an associated increase in postoperative morbidity.