End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches

Laparoscopy has become over the last decade one of the approaches of choice in the surgical repair of PSH. The most employed laparoscopic techniques for PSH repair are the keyhole (KH) repair [19], the Sugarbaker (SB) technique [20, 21], and the sandwich technique [22‐25]. Briefly, in the keyhole technique a mesh with a central hole or a slit allowing bowel to pass through the stoma site is positioned in an intraperitoneal fashion. Sugarbaker repairs consist in the intraperitoneal placement of a mesh to cover the stoma site after lateralizing the bowel, eventually after placement of sutures for primary closure of fascial defect to reduce the risk of recurrence [6, 26]. The sandwich technique is a combination of the KH and SB repair, using two intraperitoneal meshes. According to the original description [22], the first mesh is allocated in a KH fashion to stabilize the lateral abdominal wall in a perspective to reduce the risk of hernia recurrence in patients with a fascial defect lateral to the stoma. The second mesh is then positioned according to the SB principles accomplishing lateralization of the stoma loop. Considering these approaches as a cornerstone in PSH repair, modified techniques as well as interventions describing a combined open and laparoscopic approach have been proposed [10, 27‐29], but limited to single center or even single surgeon experience.

Several studies have compared the laparoscopic approach with the open approach, showing how laparoscopy provides decreased rates of recurrence and postoperative complications compared to the open approach [6, 30]. Recently, Keller et al. [30] evaluated 62 consecutive patients who underwent either laparoscopic or open elective repair and compared the outcome of surgery. Each group consisted of 31 patients and had similar demographic details with a similar proportion of patients with colostomy. In the laparoscopic group, the same surgical repair was adopted in all patients. Open repair was performed more often on patients with prior PSH recurrence (58% vs 29%, p = 0.004). Compared to laparoscopic repair, patients who underwent open repair showed an increased incidence of wound dehiscence (29% vs 3%, p = 0.012), while non-wound complications were similar between the two groups. The operative duration (p < 0.001) and median length of in-hospital postoperative stay were shorter in the laparoscopic group (3 days vs 7 days, p < 0.001). After adjustment for prior repair, evaluation at 3 years reported a significantly longer recurrence-free time for laparoscopic repair than the open repair (p = 0.022).

Although relatively simple and easy to master, in the KH technique the presence of the central hole or of the slitting causes a weakness in the mesh which in turn increases the risk of PSH recurrence [6, 26]. The real risk of recurrence as well as the recurrence rate by adopting this technique has not been clearly assessed and remains controversial. As a matter of fact, an incidence of recurrence as high as 20.8% has been reported [29]. In the previous review on this topic it was stated that in laparoscopic repair, the SB technique was superior over the KH in terms of lesser rate of recurrence [8]. A recent nonrandomized case-controlled prospective study, comparing the outcome of patients operated on by a KH or an SB repair using a polypropylene mesh with an antiadhesive layer, showed an incidence of postoperative complications for the KH group of 14.9%, recurrence rate of 7% and late mesh-related morbidity of 8%. These results, with regard to end-colostomy PSH, did not differ significantly from those reported after an SB repair, in which postoperative complications were 11.5%, recurrence rate 10% and late mesh-related morbidity 10%. Therefore, KH repair produces outcomes somewhat similar, especially over the follow-up to the SB technique [24]. Similar results were obtained by Oma et al. [12]: in a cohort of 79 patients, the overall recurrence rate was 9%, without a significant difference in the risk of recurrence after KH compared to SB repair (1/10 = 10% vs 6/67 = 9%, p = 1.00).

Rajapandian et al. [26] looking for lesser and acceptable recurrence rates described the outcome of 23 patients, 18 of them with colostomy PSH, operated on with a modified KH repair. The technique consisted of an almost complete removal of the hernial sac to reduce the incidence of postoperative seroma, while to reduce the risk of recurrence the wall defect was approximated with a non-adsorbable suture, and the bowel fixed to the parietal wall with seromuscular sutures. The mesh was incised from one side to create a half slit to surround the bowel, with the cut margins overlapping each other and fixed with transfascial and intracorporeal sutures. No major intraoperative complications, such as bleeding or bowel injuries, or postoperative complications occurred. A further attempt in reducing recurrences through a modified KH repair was described by Olmi et al. [29] in a cohort of 90 patients, with 83 (92.2%) of them suffering an end-colostomy PSH and with a mean BMI of 30 kg/m² (range 28–34). Repair was carried out through a reduction of the defect with multiple sutures with extracorporeal knotting, later covered and reinforced with a polypropylene mesh fixed with tacks. The stoma is fixed by suturing the edge of the defect and extracorporeal knotting, then the mesh with a slit of 3 cm in width for the stoma and an overlap of 5 cm is placed with the mesh border overlapped to create the KH. Finally, the mesh was fixed with a double crown of tacks. Postoperative complications consisted of seroma in four patients (4.4%), managed conservatively. Recurrence occurred in four patients (4.4%), in one case on postoperative day 7 due to technical error. Yan e al [10], in their series of 65 consecutive patients, 60 of them with colostomy, evaluated the effectiveness of combining an in situ re-ostomy with the laparoscopic KH technique. The main advantages of such an approach consisted in the opportunity to have an adequate operative space to dissect the bowel, closing the defect, stitching the mesh to the stomal bowel, and resecting the redundant bowel if necessary. Postoperative morbidity included two cases of seroma and three of ileus managed conservatively, while in one case of intestinal perforation a rescue surgery with intestinal resection and entero-enterostomy warranted care. Over a median follow-up of 29 months (range 3–60 months), no complications of mesh-related infection or patch erosion were noted, recurrence was recorded in one case (1.5%), 17 months after the index surgery.

Asif et al. [6] evaluated a cohort of 49 patients with PSH without any differences in terms of demographic features. SB repair was conducted in 14 and compared with 19 laparoscopic KH, 11 re-siting, and 5 open repairs. There were no differences in terms of postoperative complications among all techniques, but the SB group showed a significantly lower rate of PSH recurrence. Hansson et al. [31] described the outcome of 61 consecutive patients, 55 with symptomatic colostomy-related PSH who underwent laparoscopic SB technique with positioning of an ePTFE mesh (Gore-Tex Dual-Mesh Biomaterial^(R), WL Gore Associates Newark, DE, USA). The morbidity rate was 19%, and one patient died due to metastasis of lung carcinoma causing a bowel obstruction. The recurrence rate was 6.6% after a mean follow-up of 26 months. DeAsis et al. [23] compared the outcome of 25 SB compared to 37 other PSH repairs including 18 KH, 13 re-siting, and 6 open repairs in a homogeneous group of 62 patients suffering from PSH. The authors proposed a modified SB technique consisting of a primary closure of the wall defect by a combined transfascial and intracorporal suture before placing the mesh. Patients who had SB repair experienced lesser postoperative complication rate (40% vs 76%, p = 0.02) as well as reduced recurrence rate (16% vs 60% p < 0.001), so showing a protective role against recurrence. Although rarely reported [32, 33], to avoid the risk of mesh infection, obstruction, fistulization or mesh erosion, Rege et al. [34] proposed a modified mesh placement technique. A composite mesh was placed with upward folding of the visceral non-adhesive surface in contact with the stomal loop with the aim of avoiding the risk of mesh erosion into the bowel or causing adhesions and subsequent stoma obstruction. In the reported series of 14 patients, over a follow-up ranging between 15 months and 7 years, no complications of mesh such as seroma formation, stomal necrosis, mesh infections and erosion, or hernia recurrence were noted. To overcome the risk of adhesions and fistula formation in the report of Bellido-Luque [35], a modified SB approach based on an extended totally extraperitoneal mesh repair was proposed. The authors described a series of 12 patients who underwent an end-colostomy PSH repair with an average follow-up of 29 months. The proposed technique where the mesh does not need helical sutures allowed a significant improvement in pain and activity restriction compared to preoperatively, no postoperative wound infections or hematomas were noted, and in two cases (16%) a seroma was detected and managed conservatively. One patient (8%) required postoperative readmission (within 1 month after the index surgery) due to partial bowel obstruction without the need of reintervention. No follow-up dropout or recurrence was recorded in the whole series [35].

By adopting the sandwich technique, in the report by Barranquero et al. [36], repair was performed in 38 patients, with a median BMI of 29.2 kg/m² whose hernia was associated with an end colostomy in 94.7% of cases. The recurrence rate was 7.9%, with a median time for recurrence of 12 months, and a median follow-up of 39 months. Also, diagnosis was made in more than 92% of patients by CT scan examination. Postoperative complications were found in the analysis as the main risk factor for hernia recurrence. Bertoglio et al. [37] compared the outcomes after repair between 13 patients who underwent sandwich technique and 19 patients operated on with a KH repair. Patients’ demographics, characteristic of the defect, and postoperative outcomes were similar between the two groups, while in the sandwich repair group a statistically significant shorter length of hospital stay (p = 0.04) compared to KH repair was noted. He recurrence rate was 21% in the KH group at the 1-year follow-up, while no overall recurrences were recorded in the sandwich group over a median follow-up of 26 months (range 13–78). Some other techniques have been reported in the literature. Fischer et al. [27] described a technique of PSH repair with a 3D funnel-shaped intraperitoneal mesh device and same-sided stoma relocation. The authors reported the results in 56 patients; end-colostomy PSH accounted for 84% and the repair was attempted by laparoscopy in 41 (73%) patients. The median follow-up time was 38 months (range 12–58 months) and over this time, if the overall recurrence rate was 12.5% (7/56), the recurrence rate in the laparoscopic group accounted for 7.3% (3/41), while in the open group it was 26.7% (4/15). The overall incidence of surgical complications was 16.7% (9/56), with major surgical complication rate of 8.9% (5/56). Szczepkowski et al. [28] described an alternative approach called hyper/SPHR technique (hybrid parastomal endoscopic re-do/Szczepkowski parastomal hernia repair). This technique consists of four steps as a combination of laparoscopic and open approach (laparoscopic stage, open stage, reconversion to laparoscopy, and final open stage with neo-stoma formation) with the use of a 3D pre-shaped mesh placed intraperitoneally with a hole in which the ostomy bowel is delivered and the funnel oriented to the visceral side of the abdomen. In this series, 12 patients with end-colostomy PSH were operated on, and a single (8.3%) postoperative complication (a small wound hematoma treated conservatively) was detected. Also, no stoma site infections, stoma-related problems, or recurrence were recorded over a 13.5-month (range 6–17 months) follow-up. A combined laparoscopic and ostomy-opening approach was also proposed by Kohler et al. [38]. The repair was based on the placement of a cylindrical-shaped mesh of 4 cm funnel length after laparoscopic adhesiolysis and an open approach with excision of the ostomy opening and closure of the bowel later delivered through the funnel of the mesh. The mesh is inserted in the peritoneal cavity through the hernia defect. Laparoscopy is then restored after suture to close the defect to fix the mesh to the peritoneum. No mesh complications were reported or recurrence noted over a 4-month follow-up (range 3–8 months). Although these are promising results, to the best of our knowledge, up-to-date results derived from a wide validation of these repairs are lacking.

Robotic surgery has been integrated into the surgical landscape for over 20 years and has particularly experienced rapid growth in the field of general surgery, in an effort to overcome the limitations that laparoscopy, and even more open surgical techniques, may impose on surgeons.

Preliminary series report encouraging results, although not yet validated by randomized controlled trials (RCTs), especially in the short term, when a robotic approach is employed in ventral hernia repair, [39‐43], and similarly happens when a robotic repair of PSH is evaluated. The present literature review has shown the paucity of these primary studies, and our aim is therefore to provide an overview of the current state of the art and to guide potential primary studies in this direction. Of the articles included in the review, five studies were analyzed for robotic repair of PSH [15‐17, 44, 45]. Four are retrospective studies, one is a prospective study, and included in total 61 patients with a median follow-up of 1 year.

Kyle et al. [44] conducted a retrospective study on the postoperative outcomes for a total of 24 patients, of whom 16 underwent colostomies treated with a modified robotic Sugarbaker technique. In any case was necessary conversion to a laparoscopic or open procedure. Two patients underwent reoperation, one during hospitalization for intestinal obstruction and the other later for the development of a hernia between the mesh used for incisional hernia repair and the mesh placed for parastomal hernia. 33% of patients had a minor complication, and there was a 16% incidence of seroma. The authors clarified that the two major complications occurred in the early period when the learning curve for using the new robotic platform was not yet optimal. With more frequent use of the platform, both the operative time and docking time were reduced. Dewulf et al. [15] presented preliminary results in a retrospective study on 62 patients: 38 of whom were operated on for end-colostomy PSH parastomal hernia. Technical considerations of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias were evaluated. Patients who underwent robotic modified Sugarbaker procedure had an average hospital stay of 2 days, an operative time of about 180 min, and there was no need for hospital readmission within 30 days postoperatively. One patient developed a recurrence, with an average follow-up of 14 months. Using the Pauli technique, transversus abdominis release (TAR) combined with the advantages of visceral parietalization, serosa injuries occurred in seven patients, and in one mucocutaneous detachment led to stoma revision, with an average operation time of 156 min, a medium hospital stay of 3 days, and mean follow-up of 14 months. There were minor postoperative complications in eight patients, one patient had a recurrence, and one patient had stoma necrosis. For patients who received a funnel-shaped mesh, longer mean operative times was noted, 201 min, but the authors state that the funnel configuration facilitates stoma irrigation, which could otherwise be compromised by the lateralization of the intestine after the modified Sugarbaker and Pauli procedures. Lambrecht [45] included in his prospective observational study 15 patients with parastomal hernia who underwent a repair procedure, termed ePauli with transversus abdominis release (TAR), 9 of whom were approached robotically. The experience, although limited and with an average follow-up of only 10 months, has shown encouraging results in terms of complications, feasibility, and recurrence. The surgical technique used was technically challenging, but feasible, safer, and less strenuous when performed robotically, and more suitable for patients with recurrent parastomal hernia who had previous hernia repairs with intraperitoneal or retromuscular mesh.

Ayuso et al. [17] retrospectively analyzed the demographic data and monitored intraoperative and postoperative outcomes for 15 patients operated on by robotic Sugarbaker technique for parastomal hernia repair, of which 4 had an end colostomy. The average operative time was 182 min, and there was only one recurrence observed over an average follow-up period of 14.2 months. In conclusion, the robotic Sugarbaker technique has proven to be safe and technically feasible, with low rates of short-term recurrence and minor complications. Another robotic technique reported in the literature is analyzed by Maciel et al. [16], who presented data obtained from a retrospective analysis of two patients who underwent robotic retromuscular parastomal hernia repair, in both cases involving colostomy and midline incisional repair. The follow-up period was 1 year for both patients, and no recurrences were observed. According to the authors, in agreement with other studies included in the review, the technique is certainly challenging and requires a high level of surgical expertise with abdominal wall dissection techniques, and a longer operative time compared to laparoscopic techniques.