Parastomal hernias are the most common long-term complication following ostomy surgery, with a very high incidence rate (50%) and recurrence rate even after repair (18%) (1, 2). Various techniques such as open, laparoscopic, and robotic surgery have been described for parastomal hernia repair (3). Commonly used laparoscopic repair techniques are the keyhole, Sugarbaker, and sandwich (4–6). An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia, which involves placing an anti-adhesion mesh with a special coating in contact with the bowel. However, mesh placement within the peritoneum carries the risk of intestinal adhesion or fistula, which can be life-threatening (7).

Satisfactory results have been achieved in the laparoscopic repair of various types of hernia using the totally extraperitoneal (TEP) technique (8–12). However, the laparoscopic repair of parastomal hernia with a TEP technique rarely been reported, and there is little evidence of laparoscopic application. We previously reported the successful separation of the peritoneum with this technique and repair of a parastomal hernia using a synthetic mesh without anti-adhesion coating (12). In that case, the sigmoid colon was short and adhered to the ventral wall with a certain degree of tension; we therefore selected a keyhole-like method for laparoscopy (12). However, repair of a parastomal hernia using a modified laparoscopic Sugarbaker method is preferable to a keyhole mesh (1) because the bowel at the stoma can be treated in the same manner as the spermatic cord in inguinal hernia surgery. Here we describe laparoscopic parastomal hernia repair in 7 patients using a TEP approach and Sugarbaker mesh configuration. This technique eliminates the need to move the stoma or cut the mesh during its placement.

A standard surgical technique was used for all patients. General anesthesia was used in all surgeries, with the patients placed in the supine and Trendelenburg position. The patient's abdomen was painted with 7.5% povidone–iodine and a surgical scrub was placed from the nipple to the knee. The peristomal area was cleaned with 10% povidone–iodine solution and the stoma was sealed with an adhesive incise drape. The surgeons were standing contralateral to the stoma with the monitor over the surgical site.

Seven patients with a mean (±SD) age of 62.2 ± 5.7 years, mean body mass index of 28.7 ± 3.7 kg/m², and average American Society of Anesthesiologists class 3 underwent hernia repair. The patient's characteristics are detailed in Table 1. None of the patients had prior parastomal hernia repair. The average parastomal hernia defect size was 3.1 ± 2.7 cm. All seven patients had end colostomies following open abdominoperineal resection for rectal cancer. Diabetes was the most frequent comorbidity, followed by hypertension and chronic obstructive pulmonary disease. Four patients were active smokers. A polyester mesh without anti-adhesion coating was used in all patients who underwent repair.

The mean size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm². The mean operative time was 195.5 ± 20.7 min. One patient developed subcutaneous emphysema (Table 2). The average follow-up time was 8.5 ± 2.7 months. Mild pain occurred in 2 patients; 3 experienced seroma formation (with no special treatment required); and there was 1 case of early intestinal obstruction (treated with conservative care). The patients were discharged an average of 4.8 ± 2.1 days post surgery. There were no stoma-related complications, mesh erosions, or intestinal obstruction in the follow-up examination (Table 3). Routine imaging performed at 3 months revealed no recurrences of hernia.

Parastomal hernia is a common and challenging complication following stoma creation that has a higher incidence rate than other types of incisional hernia. The main risk factors for the development of parastomal hernias are obesity, age, malignancy, inflammatory bowel disease, wound infection, steroid use, diabetes, loop ostomy, and emergency surgery (14). The laparoscopic repair of parastomal hernia with a TEP technique has rarely been reported, and there is little evidence of laparoscopic application. Laparoscopic Pauli (ePauli) repair was first reported in a peer-reviewed publication by (15) as an enhanced-view TEP repair approach that is technically feasible and has the potential advantage of avoiding intra-abdominal adhesions, but likely has a greater risk of adhesiolysis of the intestine in the parastomal hernia sack. Recently, Lambrecht et al. reported their initial experience with endoscopic preperitoneal parastomal hernia repair (ePauli repair) (16).

We successfully separated the peritoneum with a laparoscopic TEP approach (12) and repaired the parastomal hernia using a modified Sugarbaker technique. The difficulty of this approach was in the creation of an extraperitoneal space around the stoma. While dissecting, it is critical to move along the abdominal wall. We previously reported that there are several easily separated spaces on the abdominal wall (Figure 2) (12). We emphasize here that 2 types of separation can be performed in the middle abdomen—ie., between the rectus abdominis and posterior sheath, and between the posterior sheath and peritoneum (12). The peritoneum is usually extremely thin and adheres tightly to and cannot be separated from the posterior sheath. However, we demonstrated that the “space between the peritoneum and posterior sheath can be separated,” thus laying a foundation for TEP repair of parastomal hernias. In order to protect the function of the abdominal wall, the posterior sheath structure should be dissected as little as possible. In cases where adhesiolysis was difficult, we opened the peritoneum (Figure 3A); this allowed observation of the intestine within the abdominal cavity and reduced the risk of accidental injury. In cases where there was little adhesion, we moved along the extraperitoneal space (Figure 3B). There are several different approaches to entering the extraperitoneal space (16, 17) that require dissection of the transversus abdominis muscle. In contrast, with our technique it was unnecessary to release the transversus abdominis (Figure 3B); we believe that this helped to preserve the strength of the abdominal wall.

Currently, there is no uniform standard for meshes used in the Sugarbaker procedure. Meshes reported in the literature include polypropylene, expanded polytetrafluoroethylene, polyvinylidene difluoride, polyester, and biological meshes (1). In our cases, we used a polyester mesh without anti-adhesion coating. Mesh placement outside the peritoneum effectively avoids intestinal adhesion incidents and allows the use of ordinary mesh, thus reducing costs. Tack is the most common choice of material for mesh fixation; we used 5-mm titanium helical tacks and the modified laparoscopic Sugarbaker procedure to reliably fix the mesh, with mild postoperative pain and a low recurrence rate. The patients were discharged an average of 4.8 ± 2.1 days after the surgery, with no postoperative complications such as pain, bleeding, or sepsis.

With advances in laparoscopic technology, many patients with rectal cancer prefer treatment by laparoscopic surgery. For patients with a parastomal hernia after laparoscopic Miles surgery due to a small surgical scar on the abdominal wall (18), it should be easy to separate the preperitoneal space; applying the TEP approach to repair the parastomal hernia is feasible. We repaired parastomal hernias with the TEP approach in 7 patients with a history of open abdominal surgery. However, there are some technical difficulties in this operation and the operative time is long.

Compared to other laparoscopic techniques, ours has the following advantages:

However, our technique also has the following shortcomings:

Subcutaneous emphysema is a potential complication of laparoscopic surgery but is more likely to occur in extraperitoneal surgery as insufflated CO₂ can easily diffuse into surrounding tissues. High insufflation pressure increases the risk and is the most likely cause of this complication (19, 20). The rapid diffusion of CO₂ and occurrence of subcutaneous emphysema can be attributed to the fact that the extraperitoneal space is continuous with the subcutaneous space. Subcutaneous emphysema was managed during the laparoscopic procedure by avoiding high CO₂ insufflation pressure, applying hyperventilation, and discontinuing N₂O, which rapidly enters the gas space containing CO₂ and contributes to the gas volume (21). In our case series, 1 patient developed subcutaneous emphysema. Lung ultrasound was immediately performed to exclude pneumothorax. The patient recovered within 3 days after the operation without special treatment.

In a study that used the retromuscular Sugarbaker technique to repair parastomal hernia, stoma necrosis, bowel obstruction, and perforation were observed during the long-term follow-up (22). In our patients, there were no mesh-related complications up to 8.5 ± 2.7 months post surgery. One patient had early intestinal obstruction 1 month later, which is typical after a colostomy and was unlikely to be related to the procedure that we performed. We provided conservative care and the patient recovered within a few days. A laparoscopic approach through a keyhole or slit in the mesh is associated with a high recurrence rate (37%) (23). The laparoscopic repair of parastomal hernias using the modified Sugarbaker technique with a non-slit mesh and lateralization of the bowel is promising, although the clinical efficacy, recurrence rate, and late complications require confirmation in more cases with long-term follow-up.

Modified Sugarbaker repair of parastomal hernia with a TEP approach is a safe and feasible procedure, even in patients with a surgical history of open rectal resection. Although long-term outcomes are unknown, this novel approach offers a new option for the surgical treatment of parastomal hernia in the future. Further studies examining long-term recurrence rates and randomized control trials are needed in order to make definitive recommendations.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

The studies involving human participants were reviewed and approved by The Medical Ethics Committee of Northeast International Hospital (2019-new-01). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

MW and HJ contributed to study conception and design, data acquisition, interpretation, and drafted the manuscript. DT contributed to data analysis, interpretation, and drafted the manuscript. XC and CM contributed to data acquisition and interpretation. All authors critically revised and approved the final version.

This study was supported by The Scientific Research Projects for Higher Education in Inner Mongolia Autonomous Region (grant no. NJZZ21027), Support Plan for the Innovation and Entrepreneurship Initiation Plan for Overseas Students in Inner Mongolia Autonomous Region (grant no. MOHRSS2020122), and Doctoral Start-up Fund of the Affiliated Hospital of Inner Mongolia University for the Nationalities (grant no. MDFY2020001).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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