Anna R Spivak, DO, Jonathan Y Gefen, MD. Lankenau Medical Center
We present the case of a 71 year old female with a recurrent parastomal hernia that had failed two prior anterior repairs. At the site of her left lower quadrant end colostomy, there was a 4cm defect containing a massive amount of unobstructed small bowel. We repaired the hernia using a hybrid Sugarbaker /transversus abdominus release (TAR) with a robotic approach. This combined the Sugarbaker method of stoma lateralization and subfascial mesh placement, with the component separation and extraperitoneal mesh positioning of the TAR procedure. We believe this provides a combination of durability and safety while maintaining a minimally invasive approach.
The DaVinci Xi platform was used. One 12-mm port, two 8-mm ports, and one 5-mm port were placed in the right side of the abdomen. Midline adhesions were lysed, and the left lower quadrant parastomal hernia contents were reduced. The medial aspect of the left posterior rectus fascia was incised vertically. The retrorectus space was developed with blunt dissection and electrocautery. A transversus abdominis release was performed medial to the perforating vessels, and the preperitoneal plane was developed. By approaching the colostomy from above and below, the preperitoneal plane was opened circumferentially around the colostomy.
The posterior layer of the hernia defect – the posterior rectus fascia with parietal peritoneum – was closed with sutures medial to the colostomy. The anterior layer was separately closed on the medial side of the colostomy. This lateralized the descending colon and stoma conduit. Next, a laparoscopic self-fixating mesh was placed on the anterior layer. A small notch was created on the lateral side of the mesh to accommodate the lateralized colostomy and extend laterally superior and inferior to the stoma. A patch of biologic mesh was placed between the colostomy and self-fixating mesh to prevent mesh adherence to the colon. After satisfactory placement of the mesh, the initial incision in the posterior rectus fascia was closed in the midline. This repair achieved placement of the mesh outside the peritoneal cavity, closure of the hernia defect medial to the colostomy, and lateralization of the colostomy. Her recovery was uneventful, and she was discharged home on postoperative day 3. At two months follow-up, there is no sign of recurrence or discomfort.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95777
Program Number: V303
Presentation Session: Video Loop Day 3
Presentation Type: VideoLoop
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