Collin E Brathwaite, MD, Keneth Hall, MD, Alexander Barkan, MD, Michael Maglione, PA. NYU Winthrop Hospital
Introduction: Parastomal Hernia (PSH) is the most common complication of an ileostomy or colostomy with occurrence rates of up to 56% being reported. Many patients can be successfully managed non-operatively. Indications for surgery include chronic obstruction, pain, difficulty maintaining the stoma appliance or skin breakdown. Open repair is associated with a high rate of morbidity and recurrence. The surgical options include primary repair, relocation of the ostomy and reinforced repair using synthetic or biologic mesh. Despite the growth of laparoscopy in other conditions, the adoption of the laparoscopic approach has been low. In one report, only 10.4 % of 2,167 patients who underwent PSH repair from 2005 to 2011 were treated laparoscopically. Although good results have been reported in some case series, recurrence rates as high as 46% have also been reported after laparoscopic repair. Two primary intraperitoneal techniques have been described to repair a PSH. These are the “keyhole” technique and the “Sugarbaker” technique. The keyhole technique involves creating a slit with a defect in the mesh to accommodate the bowel as it enters the abdominal wall. In the Sugarbaker technique, after repair of the hernia defect, the bowel is lateralized and covered with mesh to allow a 5cm overlap. Recent studies have suggested that the Sugarbaker approach is associated with improved outcomes. The technique has been reported laparoscopically but the robotic approach in this area has been only infrequently described.
Case Report: A 75-year-old woman presented with a large PSH, having undergone a laparoscopic Abdominal Perineal Resection (APR) for rectal cancer 4 ½ years earlier. She had a permanent colostomy. She had noted the hernia 1 year after APR and had experienced several bouts of small bowel obstruction over 3 ½ years. She electively was taken to the operating room for robotic repair of the PSH using the Sugarbaker technique. The robot was docked on the patient’s left side with 3 trocars placed on the right lateral abdomen. A right sub-costal 12 mm trocar was placed with an 8mm robotic trocar through this, then 8 mm robotic trocars in the right mid abdomen and right lower quadrant. After adhesiolysis, the defect was closed with a running barbed unidirectional suture then a porcine derived biologic mesh placed. The mesh was secured with a combination of sutures and tacks.
Result: The postoperative course was uneventful.
Conclusion: Robotic Sugarbaker repair is feasible. Prospective study is warranted.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88429
Program Number: V226
Presentation Session: Thursday Video Loop (Non CME)
Presentation Type: VideoLoop