Open Parastomal Hernia Repair with KeyBaker Mesh Placement Technique

Abstract

This video demonstrates a case involving an open parastomal hernia repair with retromuscular KeyBaker mesh placement. The case involves an obese patient with a large symptomatic parastomal hernia repair after a laparoscopic end sigmoid colostomy. The CT scan shows an intact linea alba with a 7-cm parastomal defect involving the small bowel and sigmoid colon. The use of a retromuscular KeyBaker mesh placement provides the advantages of offsetting the fascial and peritoneal defects afforded by a standard Sugarbaker repair with the added benefit of reinforcing the lateral abdominal wall by performing a keyhole slit in the mesh.

Keywords

Complex abdominal wall reconstruction; parastomal hernia; Keyhole; Sugarbaker; TAR.

Case Overview

Background

This video shows the repair of a large complex parastomal hernia repair utilizing an open retromuscular KeyBaker approach.

Focused History

71-year-old female with BMI of 33 Kg/m². She had several complications after multiple childbirths that resulted in a rectovaginal fistula. The fistula was attempted to be repaired with several failed local advancement flaps. She subsequently underwent a laparoscopic end sigmoid colostomy for permanent diversion. She has developed a large symptomatic parastomal hernia involving her small bowel that resulted in difficulty pouching and a large bulge.

Physical Exam

An obese patient with a bulge in her left lower quadrant around the stoma site. There were no midline defects.

Imaging

The CT scan will be reviewed in the video. It highlights the anatomic location of the defects and the inherent challenges of repairing parastomal defects while keeping the stoma intact and providing adequate mesh overlap as well as reinforcing the midline incision.

Natural History

There are many options for repairing parastomal hernias. None of them are perfect, and all of them are associated with a fairly high anatomic recurrence rate. Therefore, it is important to mention that a non-operative approach is always worth considering. I tend to offer repair to those patients with significant pain, difficulty pouching, and obstructions. In the absence of those symptoms, I will offer observation.

Options for Treatment

A minimally-invasive approach can also be considered, particularly for smaller defects, without a midline component and not a hostile abdomen. The case depicted in this video would be amenable to an MIS IPOM Sugarbaker approach; however, in my hands the defect is a bit too large, and thus I opted for an open approach. When repairing parastomal hernias, the surgeon must consider what type of mesh they will utilize, which layer in the abdominal wall they will secure it, and how the mesh will be configured around the stoma. There are many options, and none have demonstrated superiority. Likely, outcomes are more related to surgical technique. I prefer a retromuscular repair with posterior component separation and a KeyBaker type of mesh configuration with medium weight polypropylene mesh.²

Rationale for Treatment

In patients with symptomatic parastomal hernias, an attempted repair offers the patient the best chance at improved quality of life. In addition, it will reduce the risks of requiring emergency surgery.

Special Considerations

It is imperative to have the patient marked preoperatively with a stoma therapist to give multiple alternative sites for stoma positioning. I prefer to have at least one option on each side.  Importantly, performing a Sugarbaker or Keybaker type repair requires some degree of angulation of the bowel.^1,3 Therefore, it is difficult to position an ileostomy on the left side, or a sigmoid colostomy on the right side. If anatomy mandates that type of approach, I prefer to perform a keyhole-type repair.

Discussion

The operation begins by making a generous midline incision that allows the surgeon adequate exposure to encircle the stoma. After adhesions are lysed and the bowel is reduced from the hernia, it is important to circumferentially mobilize the stoma off the fascial edges to avoid injury during subsequent retromuscular dissection.

I place a countable towel over the intestine to avoid injury during dissection of the abdominal wall. I typically begin retromuscular dissection on the side of the stoma at a fair distance from the ostomy. Once I identify the rectus muscle, I extend superiorly and inferiorly and then dissect laterally. This part of the operation can be challenging as there is a stoma going through the rectus muscle and it must not be injured. I typically place two Kochers on either side to remind me that it is at this location. I then perform a posterior lamella and transversus abdominis release (TAR) both above and below the stoma, in essence encircling the bowel. Then I can manipulate the intestine to perform the lateral release next to the bowel. After that is completed, I perform a lateral slit on the peritoneum in the orientation that the bowel will naturally lay laterally. Ideally this is for at least 5 cm. Then I close this medially to provide the angulation necessary for the Sugarbaker orientation. In this case, I performed a contralateral retrorectus dissection. However, if more overlap is needed for a concomitant midline incision, or there is too much tension on the posterior sheath, I will perform a TAR release on that side as well. The peritoneum is then closed completely excluding the mesh from the bowel.

I utilize a 30x30-cm medium-weight polypropylene mesh in a diamond configuration. Around the stoma, I allow it to lay against it in a typical Sugarbaker fashion. However, after identifying the edge of the bowel next to the mesh, I will make a keyhole slit in the mesh and wrap the tails around the stoma. I typically do not place any further sutures in the mesh and allow the tails to overlap. This essentially provides the advantage of a Sugarbaker type repair with offsetting the muscle and peritoneal openings, and a keyhole repair by providing lateral reinforcement of the abdominal wall. We have termed this approach a KeyBaker to highlight the dual nature of the repair. Drains are placed on the mesh and the skin is closed. We typically do not rush these patients’ diets as it is common to get some edema around the stoma and the acute angle can result in early postoperative ileus or even obstructions. This patient made an uneventful recovery and was discharged on postoperative day 5.

Equipment

This operation can be performed with minimal equipment and an inexpensive uncoated polypropylene mesh.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.