passer to pass the two tails of a suture placed on the lateral side of a prosthesis through the lateral edge

of the rectus sheath through separate fascia openings. The suture is then tied in the subcutaneous tissue

resulting in a secure anchoring of the prosthesis in the abdominal wall. If the subcutaneous tissue

dissection from the anterior rectus sheath has not been too extensive, the sutures cannot be retrieved in

the subcutaneous tissue and therefore the suture passer is pushed through the entire thickness of the

subcutaneous tissue and then through a small stab incision in the skin. The suture is tied and the knot

allowed to retract back into the subcutaneous tissue and the skin is approximated over it. The procedure

is completed by reapproximating the anterior rectus sheaths, thus bringing the rectus muscles back to

their normal configuration. The best long-term results are obtained when the anterior fascia can be

closed bringing the muscles back together because of an improvement in abdominal wall mechanics.

However, it is sometimes impossible to achieve this and the gap must be bridged with a prosthesis (Fig.

72-40).

Figure 72-40. Fixation of prosthesis to the peritoneal surface of the abdominal wall with the use of a suture passer. Step 1: The

suture passer device with a heavy nonabsorbable suture is passed through a 3-mm stab incision in the skin at an oblique angle.

The device and suture traverse the entire abdominal wall and then the prosthesis. Once the peritoneal cavity is entered, the suture

is released and the passer is withdrawn back into the subcutaneous tissue. Step 2: The device is redirected at a different angle

through the abdominal wall and prosthesis and the suture is grasped. Step 3: The suture is pulled out of the abdominal cavity so

that the two free ends are extracorporeal. Step 4: The suture is tied with the knot resting on the fascia. The skin is then closed.

Role of Flaps and Grafts

The use of flaps and grafts is usually reserved for patients in whom a conventional component

separation repair with a retromuscular prosthesis is not possible. Free fascia lata grafts, autodermal

grafts, and pedicled or free vascularized flaps have been reported, but are reserved for the most

complex abdominal wall reconstructions.

Laparoscopic Ventral Hernia Repair. This operation was developed in the 1990s as a natural

extension as surgeons became trained in the laparoscopic method for many commonly performed

abdominal procedures. The greatest value of laparoscopic surgery is that reapproximation of abdominal

muscles can be performed and the “gold standard” sublay technique can be replicated by the intraabdominal placement of a submuscular prosthesis, eliminating the need for the extensive abdominal

wall dissection implicit in the conventional operation.53 ePTFE has a long track record of safety with

contact with intra-abdominal viscera, and the development of the adhesion barrier–coated mesh

prosthesis has made intra-abdominal placement more attractive. Laparoscopic surgery provides several

advantages including decreased blood loss, lower wound infection rates, decreased hospital stay, and

patient preference.125,146 Improvements in wound complications and recurrence rates have not been

consistently demonstrated. Seromas are more commonly seen with laparoscopic repair but these mostly

resolve uneventfully without needing additional intervention. Certain absolute contraindications to

laparoscopic ventral hernia repairs exist including patients with hemodynamic instability and bowel

compromise.

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Entrance to the abdominal cavity followed by adhesiolysis can be problematic for a surgeon

performing a laparoscopic ventral hernia repair and devastating complications are possible, which is the

Achilles heel of this operation. This is because patients with incisional hernias by definition have had

previous abdominal surgery and the midline is commonly not usable for initial access because of a

previous incision in the area. The surgeon must make an educated guess as to the least likely place for

significant adhesions as well as be familiar with alternative access techniques away from the midline.

Unrecognized visceral injury can be the consequence if extreme care about entrance and adhesiolysis is

not maintained. These injuries commonly go undetected until the patient develops signs of septic shock

because it is difficult to differentiate peritoneal signs from ordinary postoperative pain. This accounts

for the significant mortality with this complication. Surgeons performing laparoscopic ventral hernia

repairs must have the good judgment to abandon the procedure in the face of a hostile abdomen. Left or

right upper quadrant, subcostally, is generally a safe access site for the initial port.125

Once the abdomen has been safely entered and the adhesiolysis completed, the abdominal contents

are reduced from the hernia defect under direct laparoscopic guidance. The number and location of the

sites of cannula placement vary depending on the size and location of the hernia. Once all the hernia

defects are identified, the operating surgeon must make a decision to either continue the procedure

laparoscopically or convert to an open operation. In our opinion, multiple “swiss cheese defects” are the

best indication for a laparoscopic repair. On the other hand, if there are only one or two defects with

wide separation of the muscles, the laparoscopic repair is not as effective for two reasons: (a) the

prosthesis will tend to balloon out through this defect, simulating a recurrence even though the hernia is

technically repaired, and (b) abdominal wall dynamics are addressed more effectively if the muscles can

be reapproximated. The muscles can commonly be approximated using a suture passer/trocar site

closing device similar to that demonstrated in Figure 72-40. Our group favors conversion to an open,

conventional operation in situations where it is not possible to reapproximate the muscles, but this

philosophy is not shared by all. Even in the event of conversion, laparoscopy can be used as a useful

adjunct to perform initial adhesiolysis and to examine the closure at the end of the repair to ensure

approximation of fascial edges and rule out any inadvertent injury to intra-abdominal organs from the

repair.

If laparoscopic hernia repair is planned, after initial adhesiolysis and examination of the defect, the

prosthesis is prepared by placing absorbable sutures extracorporeally around its circumference with long

tails extending from the nonadhesion barrier side. It is then rolled up and introduced through the largest

cannula. After it is unrolled, a suture passer is introduced into the abdomen to grasp each of the suture

tails through a single stab incision but separate musculofascial openings in array, which corresponds to

the previously placed prosthesis sutures (Fig. 72-40). The sutures can be tied extracorporeally and the

knot allowed to retract back into the subcutaneous tissue of the stab incisions. The skin is then closed

over them. It is important that the prosthesis be positioned onto the peritoneum so that it widely

overlaps the hernia defect (4 to 6 cm, at least). The prosthesis is further secured to the anterior

abdominal wall with staples, tacks, or sutures using the suture passer technique.

Table 72-13 European Hernia Society (EHS) Classification of Parastomal Hernias

PARASTOMAL HERNIAS

Parastomal hernia is an incisional hernia related to the presence of an ostomy which can have

significant effects on the patients’ quality of life, physical and psychological well being, and health care

resources.147 The incidence of parastomal hernia varies with the type of the stoma (1.8% to 28% for

ileostomy and 4% to 48% for colostomies).148,149 Studies designed with very careful follow-up suggest

that a paracolostomy hernia develops in more than 50% of patients followed for longer than 5 years

with most occurring in the first 2 years. The true incidence of parastomal hernias has been difficult to

quantify given the lack of uniform definition of what constitutes a hernia, variable follow-ups, and

inadequacy of physical examination to diagnose early occurrences.150 Poor site selection or technical

errors, such as making the fascial opening too large, excessive splitting and stretching of muscle fibers,

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epigastric nerve denervation, placing a stoma in an incision, or emergency rather than elective creation

of stoma, account for some of these hernias. Placing a stoma lateral to the rectus sheath is widely touted

as a cause, but this is now being challenged. Obesity, malnutrition, advanced age, collagen

abnormalities, postoperative sepsis, abdominal distention, constipation, obstructive uropathy, steroid

use, and chronic lung disease also contribute. Other techniques for stomal construction, such as

extraperitoneal tunneling, stapled ostomy, and prophylactic mesh reinforcement for permanent

colostomies especially in the posterior sublay position have been suggested, but their role in prevention

of parastomal hernias is uncertain given the lack of randomized controlled trials and good quality

evidence. A classification system for parastomal hernias has been recommended based on the size and

presence of a concomitant incisional hernia by the European Hernia Society (Table 72-13) which will

help standardize the definition of parastomal hernias for future studies.151

Fortunately, patients tolerate these hernias well. Most of the parastomal hernias are asymptomatic

and therefore can be treated conservatively. Fewer than 20% of patients with parastomal hernias have a

complication that mandates repair, and life-threatening complications, such as bowel obstruction or

strangulation, are rare. Routine repair is therefore not recommended. Table 72-14 lists possible

indications. The three general types of stomal hernia repair are fascial repair, stomal relocation, and

prosthetic repair, which can be performed either laparoscopically or open. Fascial repair involves a local

exploration around the stoma site, with primary closure of the defect. This approach is associated with

up to 75% recurrence rate152 and should be considered of historical interest only. Stomal relocation150 is

usually indicated in patients with other stomal problems, such as skin excoriation or suboptimal stomal

construction. The major drawbacks of stomal relocation are the fact that a laparotomy is required,

which in and of itself causes more morbidity than some of the other techniques, and that it exposes the

patient to the risk of three new incisional hernias at (a) the old stoma site, (b) the laparotomy incision

site, and (c) the new stoma site with reported recurrence rates ranging from 24% to 86%.

Table 72-14 Indications for Repair of a Parastomal Hernia

Whenever possible, a prosthetic repair should be considered as this appears to be the most effective,

although few randomized trials have been performed to unequivocally prove this. Options for the

location of mesh placement in parastomal hernia repair are as follows:

1. Onlay with the mesh placed anterior to the anterior rectus aponeurosis. A hockey stick incision is

usually performed outside the boundaries of the patient’s appliance (Fig. 72-41). The skin and

subcutaneous tissue are then undermined to identify the fascial defect, which is closed primarily and

reinforced with a prosthetic onlay. The problem with this approach is that the undermining of

subcutaneous tissue leads to seroma formation, which sometimes goes on to infection. Recurrence

rates of up to 26% have been reported with this technique with a mesh removal rate up to 23%.153

2. Inlay with the mesh placed to bridge the defect and sutured to the fascial edges. This alternative has,

in multiple series, been shown to have the highest chance of recurrence and suffers from the seroma

problem, as with the onlay.

3. Sublay with the mesh placed dorsal to the rectus muscle and anterior to the posterior rectus sheath or

mesh placement between posterior rectus sheath and peritoneum has been described in small case

series. Posterior component separation with retromuscular mesh positioning is a technique that has

been described in patients with complex parastomal hernias which uses mesh to reinforce all “at risk”

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areas for recurrence.154

4. Intraperitoneal inlay mesh (IPOM). An intra-abdominal prosthetic repair eliminates the need for the

abdominal wall dissection and is therefore becoming increasingly popular. It also enlists the

mechanical advantage of placing the prosthesis on the peritoneal side of the abdominal wall.155 The

intra-abdominal approach is particularly suited for laparoscopy, and several techniques have been

described.156 This can be performed in two ways. (1) The Sugarbaker technique which involves

securing the mesh over the entire fascial defect circumferentially except laterally where the bowel

exits to create a mesh flap valve around the stoma. This decreases the amount of contact with the

stoma, decreasing the chances of infection. (2)The Keyhole technique where a 2- to 3-cm cutout is

made in the mesh for the ostomy while widely covering the defect. This can be tricky as too small of

an opening can obstruct the enterostomy while too large of an opening can result in recurrence.

Figure 72-41. Repair of a parastomal hernia. A: Incision around hernia. B: Hernial sac is identified, the contents are reduced, and

the peritoneum is closed. C: The edges of the fascial defect are reapproximated. D: The fascial repair is reinforced with

polypropylene mesh, which is wrapped around the subcutaneous portion of the colon and sutured in place.

5. Laparoscopic repair of parastomal hernia. Laparoscopic repair of parastomal hernias has the

advantage of avoiding a large incision while providing superior view of the defect and allowing for

intraperitoneal mesh placement.157 Currently descried techniques of laparoscopic repair include: (1)

modified Sugarbaker technique, (2) Keyhole technique, and (3) Sandwich technique which combines

both these approaches. Reported recurrence rates range from 0% to 47% with infection rates up to

16%, conversion rates range from 0% to 15% and 10% rate of mesh explantation. The most common

mesh used for laparoscopic repair is ePTFE which is inert and more resistant to adhesions and erosion

compared to standard mesh.

Prophylactic Mesh Placement

Recent randomized controlled trials and a recent meta-analysis have shown that prophylactic

implantation of both biologic and synthetic mesh in a preperitoneal or sublay position for both

ileostomies and colostomies is safe and effective and may be associated with some of these studies

showing a decreased incidence (15% vs. 52%) of parastomal herniation.158,159 Synthetic meshes are cost

effective without added morbidity or mortality. These studies have had limitations such as small sample

size, heterogeneous population, and variable follow-up. Prospective multicenter randomized controlled

study comparing standard stoma creation to re-enforcement with porcine acellular dermal matrix

showed similar incidence of parastomal hernia at 24 months in both groups. Further large scale

randomized controlled trial with follow-up are necessary to identify specific group of patients in whom

re-enforcement is essential and cost effective and to study long-term effects of this approach.159

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