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Parastomal hernias successfully repaired using a modified components separation method: two case reports
© Suwa et al.; licensee BioMed Central Ltd. 2013
Received: 13 December 2012
Accepted: 15 May 2013
Published: 5 July 2013
Parastomal hernia is a frequent complication after enterostomy formation. A repair using prosthetic mesh by way of a laparoscopic or open transabdominal approach is usually recommended, however, other procedures may be done if the repair is to be performed in a contaminated environment or when the abdominal cavity of the patient is difficult to enter due to postsurgical dense adhesion. The components separation method, which was introduced for non-transabdominal and non-prosthetic ventral hernia repair, solves such problems.
Case 1. A 79-year-old Japanese woman who underwent total cystectomy with ileal conduit for bladder cancer presented with a parastomal hernia, which was repaired using a keyhole technique. Simultaneously, an incisional hernia in the midline was repaired with a prosthetic mesh. One year after her hernia surgery, a recurrence occurred lateral to the stoma, but it was believed to be difficult to enter the peritoneal cavity because of the wide placement of mesh. Therefore, surgery using the components separation method was performed.
Case 2. A 72-year-old Japanese man underwent an abdominoperineal resection for rectal cancer. At 5 and 12 months after his operation, a perineal hernia and an incisional hernia in the midline were repaired with prosthesis using a transabdominal approach, respectively. Three years after his rectal surgery, a parastomal hernia developed lateral to the stoma. For the same reason as case 1, surgery using the components separation method was performed. No recurrence was observed in either case as of 40 and 8 months after the last repair, respectively.
The components separation method is a novel and effective technique for parastomal hernia repair, especially in cases following abdominal polysurgery or midline incisional hernia repairs using large pieces of mesh. To the best of our knowledge, this is the first report in English on the application of the components separation method for parastomal hernia repair.
Parastomal hernia is the most common stoma complication occurring in 1.8 to 28.3% of end ileostomy and 4.0 to 48.1% of end colostomy . Although classified as an abdominal incisional hernia, the parastomal hernia is quite different from other abdominal hernias because this type of hernia tends to be exposed to contaminated environments, and a part of the hernia orifice is made of the intestinal tract. Also, as midline incisional hernias frequently occur concomitantly with parastomal hernias, some patients already have incisional hernia repairs using large pieces of mesh, which makes it difficult to enter the peritoneal cavity for parastomal hernia repair if necessary. Local fascial repair for parastomal hernias results in recurrence and should be abandoned [2–6] because of tension around the stoma. The components separation method (CSM), which has been suggested as a surgical technique that does not place stress on the atretic portion of the hernia orifice, does not need to enter the peritoneal cavity and can also be performed in contaminated environments. We report two cases of parastomal hernia successfully repaired with a modified CSM following incisional hernia repair with prosthesis.
A balloon was inflated inside the stoma, and the fascia around the stoma was tightly closed. The patient recovered well and was discharged on postoperative day 11, and as of 40 months after surgery, she has not experienced any recurrence.
Parastomal hernia is an incisional hernia related to an abdominal wall stoma  and is the most common complication of the stoma which occurs in 1.8% to 28.3% of end ileostomies, up to 6.2% of loop ileostomies, 4.0 to 48.1% of end colostomies, and up to 30.8% of loop colostomies . Many parastomal hernias are asymptomatic, but may produce problems ranging from mild parastomal discomfort to life-threatening complications such as strangulation, perforation and obstruction. The contents of the hernia may be omentum, small intestine, stomach and colon. Many patients suffer from parastomal pain, intermittent obstructive episodes and difficulty with appliance application that may result in skin irritation. Repair methods include localized fascial suturing, relocation, and use of prosthetic meshes, but the former two are not recommended as they have a high likelihood of recurrence. The literature shows that direct fascial sutures represented by the Thorlakson technique  have a recurrence rate of 46 to 100% . In the report of Allen-Mersh and Thomson , the recurrence rate of relocation with creation in the abdominal wall was as high as 57% on the same side of the stoma, which increases to 86% if created on the opposite side. Hansson et al. conducted a systematic review of the literature on parastomal hernia and stated that simple fascial suturing should not be used, and moreover that the Sugarbaker technique should be employed in laparoscopic repair . However, in a contaminated environment, or for patients who have already had prosthesis for incisional hernias making it difficult to enter the abdominal cavity, it is necessary to consider repair other than using an open transabdominal approach or with prosthetic meshes. In the cases described here, we decided not to operate using a transabdominal approach or to use prosthetic meshes, but to use a modified CSM as a tension-free fascial suture technique.
The CSM is a technique for an abdominal wall hernia repair reported by Ramirez et al. in 1990. His anatomic studies revealed that separating the external oblique fascia with an incision just lateral to the linea semilunar allows creation of a plane between the external oblique and internal oblique muscles all the way to the posterior axillary line if necessary. This method produces immediate mobility of the ipsilateral rectus abdominis muscle-internal oblique-transversus abdominis muscle complex and allows significant freedom for medial transposition of this entire complex. Surgical dissection and separation in this avascular plane totally preserves the innervation of the rectus abdominis muscles, because the intercostal nerves supplying this muscle run deep to the fascia of the internal oblique muscle, which is lateral to the linea semilunaris. This innervated muscle complex can be mobilized approximately 4cm at the subxiphoid level, approximately 8cm at the waist region, and 3cm in the suprapubic region on each side, allowing the surgeon to reconstruct defects up to 16cm in width at the waist level. An additional small amount of medial advancement (2cm on each side) can be obtained by separating the deep surface of the rectus abdominis muscle from the underlying posterior rectus sheath above the arcuate line. This procedure can contribute an additional 2cm of medial advancement for each muscle complex. Therefore, it is possible to close extremely large midline defects in a single operation.
In our cases, longitudinal incisions were made on the aponeurosis of the external oblique muscle lateral to the stoma and the anterior sheath of the abdominal rectus muscle medial to the stoma, which allowed tension-free closure of the hernia orifice enveloping the stoma edge. To the best of our knowledge, there is no report of the CSM being applied to repair a parastomal hernia besides our report in Japanese . Unlike the Thorlakson technique, which is considered not suitable, this technique enables tension-free closure of the hernia orifice, and thus seems applicable to parastomal hernias. The technical challenge of this procedure includes the degree of tightness of the fascia for closure of the hernia orifice, and the suturing of the fascia to the intestine may be controversial. However, the use of balloon inflation inside the stoma for the closure of the fascia seems to abrogate intestinal stenosis or recurrence.
The modified components separation method is an effective technique for the repair of parastomal hernia in patients who have undergone surgery using prosthetic repair for incisional hernias or abdominal polysurgery.
Written informed consent was obtained from the patients for publication of this manuscript and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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