When to use a prophylactic mesh after stoma closure: a case-control study.

PURPOSE: The closure of a stoma is frequently associated with an acceptable morbidity and mortality. One of the most frequent complications is incisional hernia at the stoma site, which occurs in 20%-40% of cases, higher than incisions in other parts of the abdomen. The objective of this study was to identify the risk factors associated with the presentation of incisional hernia after stoma closure, this in order to select patients who are candidates for prophylactic mesh placement during closure. METHODS: An unpaired case-control study was conducted. This study involved 164 patients who underwent a stoma closure between January 2014 and December 2019. Associated factors for the development of incisional hernia at the site of the stoma after closure were identified, for which it was performed a logistic regression analysis. RESULTS: 41 cases and 123 controls were analyzed, with a mean follow-up of 35.21 ± 18.42 months, the mean age for performing the stoma closure was 65.28 ± 14.07 years, the most frequent cause for performing the stoma was malignant disease (65.85%). Risk factor for the development of incisional hernia at the stoma site after its closure was identified as a history of parastomal hernia (OR 5.90, CI95% 1.97-17.68). CONCLUSIONS: The use of prophylactic mesh at stoma closure should be considered in patients with a history of parastomal hernia since these patients present a significantly higher risk of developing a hernia.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review.

INTRODUCTION: The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations. METHODS: We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis. RESULTS: Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial. CONCLUSION: A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

The Other Double Bubble Sign: Gastric Parastomal Hernia.

Introduction: A parastomal hernia (PSH) is an abnormal herniation of an intra-abdominal organ or other tissue through an intentionally created fascial defect at an ostomy site. PSHs commonly involve reducible mobile segments of omentum, intra-abdominal fat, and bowel. However, PSHs may rarely involve fixed intra-abdominal organs such as the stomach. Case Description: A 68-year-old female underwent emergent Hartmann procedure for Hinchey III diverticulitis and subsequently developed a large reducible parastomal hernia. She was scheduled for an elective laparoscopic colostomy reversal. Prior to her scheduled reversal, the patient presented to the ED with anorexia, lack of colostomy output, emesis, and pain localized to her left lower quadrant. She was found to have gastric outlet obstruction secondary to herniation of the stomach through the left lower quadrant colostomy site. The patient was admitted and treated conservatively with resolution of her symptoms, but due to the high likelihood of recurrence, the decision was made to proceed with laparoscopic Hartmann colostomy reversal with coloproctostomy and primary closure of the fascia without mesh. Conclusion: The contents of a PSH can become incarcerated causing obstruction, strangulation, necrosis and even perforation over time. Fortunately, in this case, herniation of the stomach was recognized early. The patient underwent repair of the hernia defect in order to prevent recurrence of gastric herniation and its potential detrimental complications. The decision regarding the technical aspects of ostomy reversal in terms of mesh selection require further study. In our case, mesh was not used due to patient-specific factors and comorbidities.

Baço migratório em hérnia paraestomal / Wandering spleen in parastomal hernia

The authors report a case of a parastomal hernia that incarcerated a wandering spleen. We present a very rare case of an 85-year-old woman with a giant parastomal hernia. Computed tomography revealed a parastomal hernia with a wandering spleen inside. We introduce a different and simple alternative approach, with the smallest inconvenience as possible to solve the trouble. We carried out the treatment with a prosthetic repair closing the defect with ePTFE mesh, performed through a laparoscopic approach, intraperitoneal, like a tie and move the spleen back to its anatomical place. The result was excellent.

Experiência inicial no tratamento das hérnias paraestomais / Initial experience in the treatment of parastomal hernias

O surgimento da hérnia paraestomal é uma conseqüência direta da confecção do estoma. Apesar de todos os esforços empregados na sua prevenção, a freqüência é bastante elevada e aumenta com o tempo. As alternativas de cura dessa afecção são todas cirúrgicas e várias técnicas foram propostas. Nesse artigo apresentamos uma breve revisão das alternativas operatórias que já foram apresentadas e apresentamos a técnica que empregamos. Desenvolvemos uma abordagem por videolaparoscopia com a colocação de uma tela intraperitoneal denominada nó de gravata. Em nossa série de 17 pacientes observamos bons resultados sem nenhuma recidiva até o momento.

The parastomal hernia is a direct consequence of making the stoma. Although all the efforts used in its prevention, this condition is a frequent long-term complication that increases with time. Management of the hernia is always surgical and different techniques have been proposed. In this article, the authors present a brief revision of the surgical treatment and present their own technique. The defect is assessed by videolaparoscopy and correction is performed with an intraperitoneal mesh; we call this technique "tie knot". In our 17 patients' series, we observed good results and no recurrence until now.