Richard A Perugini, MD, Nicole Cherng, MD, Justin Maykel, MD. UMass Memorial Health Care
Stomal prolapse is occurs in up to 26% of patients. It can result in pain, obstruction, ulceration, or poorly fitting appliances. Procedures involving resection are most commonly described. However, these procedures remove healthy intestine, and have a high recurrence rate. We present a laparoscopic modification of a plication technique first reported in 1955 by Lichtenstein and Herzikoff.
Our patient is a 54 year old woman with an end ileostomy following total proctocolectomy for Crohn’s disease. She subsequently underwent emergent laparotomy for incarcerated parastomal hernia requiring small bowel resection with revision of ileostomy. Since then, she has undergone multiple local revisions of her stoma for recurrent prolapse, as well as reair of midline incisional hernia. She continued to have issues with stomal prolapse.
We approached this case laparoscopically. The abdomen was accessed with a Veress needle. Minimal adhesiolysis was required. The ileostomy was identified along with some element of a parastomal hernia. We could visualize incorporated mesh from prior keyhole parastomal hernia repair. We used a 2-0 PDS V-Loc suture to decrease the fascial opening of the stoma, incorporating the mesh when able.
Next, we identified the terminal ileum leading to the stoma. This appeared somewhat edematous. We proceeded to construct a “lazy-S” configuration in the terminal ileum using interrupted 2-0 silk seromuscular sutures between bowel loops. The limbs of the “lazy S” were approximately 15 cm in length. We took care to avoid any acute angulations of the bowel. The terminal ileum was anchored in place by the mass of ileum involved in the plication.
Finally, we sutured the terminal ileum up to the peritoneum with interrupted 2-0 silk sutures so that it tracked laterally.
The patient was discharged on postoperative day #1. She was seen in follow up at postoperative day 9 and was doing well.
Stomal prolapse is a common complication. Plication of the distal intestine and concurrent repair of the parastomal hernia is technically feasible via the laparoscopic approach.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95346
Program Number: V234
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop