Jared M McAllister, MD, Wen Hui Tan, MD, Jeffrey A Blatnik, MD. Washington University in St. Louis
A 50-year-old man presented with a history of locally invasive rectal cancer requiring open low anterior resection with anterior pelvic exenteration, ileal conduit, and temporary loop ileostomy. The loop ileostomy was subsequently taken down. Over the last six months, the patient had noticed a growing bulge around his ileal conduit. He continued to have good urine output through the conduit and denied any pain. He was a non-smoker and had no other medical problems.
A CT scan of the abdomen and pelvis showed a large parastomal hernia, a small amount of midline herniation, and weakening at his former loop ileostomy site. It was decided that the patient would be a good candidate for robotic transversus abdominis release given his large parastomal defect and small midline defect.
Transversus abdominis release (TAR) is a technique of posterior component separation that provides space for wide mesh overlap of hernia defects. For this parastomal hernia repair, a keyhole technique was used since the ostomy was to be left in position and was not felt to be mobile enough for a Sugarbaker type repair.
In the operating room, extensive lysis of adhesions was performed, and small bowel was reduced from the parastomal defect. The transversus abdominis release proceeded towards the defect, beginning with incision of the posterior rectus sheath. After development of the retrorectus plane, the posterior recuts sheath was incised medial to the linea semilunaris, and the fibers of the transversus abdominis muscle below were transected. The preperitoneal plane was then developed laterally to create a space for wide mesh overlap. This process was performed on both sides of the abdomen. All hernia defects were closed with running barbed suture and a large 25×30 cm mesh was placed in the preperitoneal plane. The ostomy was left in situ with mesh situated around it in a keyhole fashion.
Postoperatively, the patient did well and was discharged on post-op day three. He was seen in clinic six weeks later with no signs of recurrence and a normally functioning ileal conduit. A postoperative CT performed for cancer surveillance showed the mesh in good position with no recurrence. This case shows that the TAR procedure is a viable option for abdominal wall reconstruction in patients with parastomal hernia defects, and that robotic technique can be used to perform this surgery in a minimally invasive fashion with good results.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87595
Program Number: V148
Presentation Session: Hernia Videos Session
Presentation Type: Video