Juan Jose Espert (Gastrointestinal Surgery and Abdominal Wall, Senior Specialist)
Hospital Clínic, Barcelona – Spain
PATIENT, SURGEONS & TROCARS POSITIONING:
The patient is placed in the supine position with both arms placed alongside the body. The surgeon and the assistant stand at the contralateral site of the stoma. In this case it is a colostomy on the left side of the patient. We use 3 trocars for this surgery. The trocars are placed on the right flank (11 mm trocar for the 30º scope), the right iliac fossa (11 mm) and the right upper quadrant (5 mm).The first trocar is placed through an open technique on the right flank for the 30º scope. We introduce the pneumoperitoneum through this trocar and then put the rest of the trocars at points previously established under direct vision. The colostomy is previously covered with Steri-Drape® to protect the surgical field. The patient is positioned toward the right side to start the procedure.
COLON AND ABDOMINAL WALL DISSECTION:
In this case it is a lateral colostomy so the first step is to convert it into a terminal stoma. The mesocolon is sectioned using the LigaSure™ to perform this step. We completed the section with rigorous hemostasis. Later the colon is sectioned using a 60 mm beige EndoGIA™ .
Finally the colon is released from the hernia sac to continue the procedure. Here we can see how the hernia sac is completely empty and the colon is free of adhesions at this level. Then a careful adhesiolysis of the proximal colon is performed.
The stoma have to be completely dissected free from the fascia and the peritoneum around the trephine opening is freed from adhesions to allow an overlap of at least 4 cm between the abdominal wall and the prosthesis, around the hernia defect.
Then we introduce the rolled mesh in the abdominal cavity. The mesh is unrolled and the trephine opening is covered with the intraperitoneally titanium mesh. The bowel is lateralized, passing from the hernia sac between the abdominal wall and the prosthesis into the peritoneal cavity. In this way a tunnel is created between the abdominal wall and the prosthesis.
The prosthesis is fixed to the abdominal wall using glue as a first step. We completed the fixation using absorbable tackers. It is of utmost importance to prevent narrowing of the bowel in the tunnel and angulation of the bowel when entering the abdominal cavity and the hernia sac. Finally we make the last adjustments using glue at the level of the the colon.
Laparoscopic parastomal hernia repair using the Sugarbaker technique is safe and feasible in experienced hands. It counts with the benefits of a minimally invasive approach, especially the low aggression to the abdominal wall in patients which already are at risk for herniation.