Parastomal Hernia Repair

Educational Objectives

The goal of this program is to improve hernia repair. After hearing and assimilating this program, the clinician will be better able to:

1. Decide whether, when, and how to perform a parastomal hernia repair.

Summary

Parastomal hernia: 50% of people with a stoma will develop a parastomal hernia; necessary to maintain a controlled hernia, tight enough to prevent additional hernia but not tight enough to obstruct the bowel; recurrence rates are between 20% and 40%; the clinician must have a thoughtful discussion with the patient about whether a repair should be done, what to expect in the long run, and what a second operation might entail

Criteria for repair: incarceration, strangulation, and obstructive symptoms require surgery; beyond those situations, quality of life metrics must be significant (eg, difficulty pouching, stomal leakage, significant pain [not simply “discomfort”]); in the absence of obstructive symptoms, consider observational follow-up every 6 mo

Nonoperative management: trusses are effective for some patients, but not all; most patients are asymptomatic

Surgical considerations: preoperative optimization is essential (eg, smokers must stop; obese patients must lose weight; glucose levels must be controlled); stoma revision — assess the need to revise the stoma; stoma revision is required for prolapse, strictures, large defects with weak fascia, excessive skin deformity, and cutaneous issues

Emergency surgery: relocating the stoma and closing the initial defect doubles the potential sites for recurrence; not ideal, but certainly acceptable in emergencies; the same may be said for primary fascial repair; for a patient with a hostile abdomen and multiple parastomal hernia repairs, may consider open subcutaneous onlay; benefits include avoidance of laparotomy and difficult lysis of adhesions

Surgical approaches: keyhole technique — may be performed via an open or minimally invasive approach; can be intraperitoneal or retromuscular; likely best for a patient who does not have a concomitant midline hernia; Sugarbaker techniques — involves placement of mesh over the defect and lateralizing the bowel; Sugarbaker surgeries are most often performed laparoscopically; short-term outcomes show no wound or mesh infections and low recurrence rate; laparoscopic Sugarbaker is most suitable for patients without a concomitant ventral midline defect and who have a small parastomal defect; shown to have lower recurrence rates than laparoscopic keyhole, with no overall difference in morbidity

Speaker’s data: surgical site infection rate 45%; all recurrences after keyhole procedures were at the new stoma site (11% at 13 mo)

Retromuscular Sugarbaker procedure: involves performing a TAR, then bringing down the bowel and lateralizing it around the mesh, while keeping the mesh in a retromuscular position; benefit includes maintaining the stoma in its initial location and keeping it covered, minimizing spillage during surgery

Readings

Aquina CT et al. Parastomal hernia: a growing problem with new solutions. Dig Surg. 2014;31(4-5):366-76; Hansson BM et al. Surgical techniques for parastomal hernia repair: a systematic review of the literature. Ann Surg. 2012;255(4):685-695; Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003 Nov 8;362(9395):1561-71; Shah NR et al. Parastomal hernia repair. Surg Clin North Am. 2013 Oct;93(5):1185-98; Tastaldi L et al. Single center experience with the modified retromuscular Sugarbaker technique for parastomal hernia repair. Hernia. 2017 December; 941–949.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Krpata was recorded at Updates in General Surgery, held February 7-10, 2020, in Vail, CO, and presented by the Cleveland Clinic Digestive Disease and Surgery Institute. For information on future CME activities from this sponsor, please visit ccfcme.org. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS680903

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation