Para-urostomy hernia - Forum

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A Doctor

Para-urostomy hernia - Ärzteforum

Post#1 »

I have a 75 year old woman, 3 years s/p ileal conduit for a neurogenic bladder, who presented with SBO due to an incarcerated para-stomal hernia. She reduced spontaneously after placement of a nasogastric tube, and is back on a regular diet. The hernia is lateral to the stoma, and the fascial defect appears to be 4 or 5 cm in diameter. The loop is fairly long based upon a recent loop-o-gram, but I am loathe to move the stoma to the opposite side of the midline due to an old paramedian incision on that side. I'm not sure if it is long enough to move to the upper abdomen, however. Would anyone consider simply repairing the hernia via an adjacent incision, possibly using Marlex mesh? I'm also curious if anyone has any experience repairing these laparoscopically with Gortex.


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Billroth

Re: Para-urostomy hernia - Ärzteforum

Post#2 »

My partner and I have repaired three parastomal hernias laparoscopically with very satisfactory results so far. No early recurrences, very quick recovery. The followup ranges from 1.5 years to 7 months. All were for colostomies.

We inflate the abdomen normally. Because of adhesions, we enter the abdomen and insufflate using a Visiport (US Surgical). We used to use Hassan technique for this type of thing, but now find it to cumbersome by comparison.

We then dissect and define the hernia sac and defect. We close the defect using intracorporeal suturing with an Endostitch device (US Surgical), then insert a piece of polypropylene mesh which is slotted for the bowel. We then secure the mesh to the abdominal wall with the spiral tacker device from Origin Medsystems. We used to use the stapler from US Surgical, but it seems to be harder to use, and requires a 10.5 mm port.

Sometimes the dissection can be challenging due to adhesions, but we have been surprised (in our limited experience) that it hasn't been as hard as one might think.

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Surgeon

Re: Para-urostomy hernia - Ärzteforum

Post#3 »

I, like you, will admit to being willing to repair one of these without being a colorectal specialist. It worked fine - open repair, sutured marlex to the internal aspect of the fascia and sutured the bowel loop to a hole just big enough for it to go through. He's had no problems with it for the last five years.

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Schom

Re: Para-urostomy hernia - Ärzteforum

Post#4 »

I dread taking care of these, but had good results with one gentleman who also had previous surgery on the contralateral side. Ended up fashioning a piece of mesh for the defect, plus extended it around the stoma.

Haven't done this laparascopically!

Montag surgeon

Re: Para-urostomy hernia - Ärzteforum

Post#5 »

I have no experience with a laparoscopic approach, but SESAP advises an adjacent incision and mesh.

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StSt

Re: Para-urostomy hernia - Ärzteforum

Post#6 »

I also have no personal experience with lap repair. Preperitoneal Marlex mesh repair by laparotomy, so as to avoid contamination from the stoma, is reported to be good. I would certainly try a lap repair next time I have a patient like yours.

Sojer

Re: Para-urostomy hernia - Ärzteforum

Post#7 »

Why do a lap repair in a patient with previous complex abdominal surgery and multiple adhesions, when preperitoneal marlex mesh repair via an adjuscent incision gives excellent results with few complications?

In our institution there have been a couple of deaths following lap repair of incisional hernias after complex operations.

While lap repair is a surgical tour-de-force, I don't think the results to date justify the added risk.

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Turkish surgeon

Re: Para-urostomy hernia - Ärzteforum

Post#8 »

Describing any lapaproscopic operation as a "surgical tour-de-force" denigrates the value of laparoscopic surgery. When I read about Eddie Reddick's first lap chole, I think I labeled it the same way. And two years later, I still was suspicious. After all, there were reported deaths after that procedure.

The reasons to try a laparoscopic parastomal hernia repair in this patient are the same reasons that laparoscopic cholecystectomy has become the standard, as have a wide variety of laparoscopic procedures replaced their open equivalent. The patient reaps substantial benefits. Besides, if the degree of adhesions is too great.

As to anecdotal reports of deaths after laparoscopic adhesiolysis, well, my anecdotal experience in three laparoscopic parastomal hernia repairs as well as a very large number of laparoscopic procedures on patients with adhesions over the last 6 years suggests that the risks of laparoscopic parastomal hernia repair are outweighed by the potential benefits. You can always bail out and repair it preperitoneally. Little to lose, a lot to gain.

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