The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study

B. M. E. Hansson 0 1 2 3 4 S. Morales-Conde 0 1 2 3 4 T. Mussack 0 1 2 3 4 J. Valdes 0 1 2 3 4 F. E. Muysoms 0 1 2 3 4 R. P. Bleichrodt 0 1 2 3 4 0 T. Mussack Department of Surgery, Klinikum der Universitat Munchen , Campus Innenstadt, Munich, Germany 1 S. Morales-Conde Unit of Innovation in Minimal Invasive Surgery, University Hospital Virgen del Rocio , Seville, Spain 2 B. M. E. Hansson (&) R. P. Bleichrodt Department of Surgery, Canisius-Wilhelmina Hospital , P.O. Box 9015, 6500 GS Nijmegen, The Netherlands 3 F. E. Muysoms Department of General Surgery , Maria Middelares, Gent, Belgium 4 J. Valdes Department of Colorectal Surgery, University Hospital Virgen Macarena , Seville, Spain Background Parastomal hernia is a frequent complication of intestinal stomata. Mesh repair gives the best results, with the mesh inserted via laparotomy or laparoscopically. It was the aim of this retrospective multicenter study to determine the early and late results of the laparoscopically performed, modified Sugarbaker technique with ePTFE mesh. Methods From 2005 to 2010, a total of 61 consecutive patients (mean age = 61 years), with a symptomatic parastomal hernia, underwent laparoscopic repair using the modified Sugarbaker technique with ePTFE mesh. Fifty-five patients had a colostomy, 4 patients an ileostomy, and 2 a urostomy according to Bricker. The records of the patients were reviewed with respect to patient characteristics, postoperative morbidity, and mortality. All patients underwent physical examination after a follow-up of at least 1 year to detect a recurrent hernia. Morbidity rate was 19 % and - included wound infection (n = 1), ileus (n = 2), trocar site bleeding (n = 2), reintervention (n = 2), and pneumonia (n = 1). One patient died in the postoperative period due to metastasis of lung carcinoma that caused bowel obstruction. Concomitant incisional hernias were detected in 25 of 61 patients (41 %) and could be repaired at the same time in all cases. A recurrent hernia was found in three patients at physical examination, and in one patient an asymptomatic recurrence was found on a CT scan. The overall recurrence rate was 6.6 % after a mean follow-up of 26 months. Conclusion The laparoscopic Sugarbaker technique is a safe procedure for repairing parastomal hernias. In our study, the overall morbidity was 19 % and the recurrence rate was 6.6 % after a mean follow-up of 26 months. Moreover, the laparoscopic approach revealed concomitant hernias in 41 % of the patients, which could be repaired successfully at the same time. A parastomal hernia is an incisional hernia related to the presence of an enterostomy [1]. It is a common complication of stoma formation and the reported incidence varies from 3 to 39 % for colostomies and from 0 to 6 % for ileostomies [2]. Most parastomal hernias are asymptomatic and therefore can be treated conservatively. Indications for surgery are illfitting appliances causing leakage, pain, discomfort, and cosmetic complaints [3]. Urgent treatment is indicated when incarceration or strangulation of hernia content occurs. Surgical treatment options are relocation of the stoma, or repair with or without the use of prosthetic material via an open or a laparoscopic approach. Recently, a systematic review of surgical repair of parastomal hernias was published by Hansson et al. [4]. It was concluded that suture repair should be regarded as outdated because of the high recurrence rate of 69.4 %. Synthetic mesh repair had significantly better results with respect to wound infection and recurrence rate. Depending on technique and placement, recurrence rates after mesh repair varied between 6.9 and 17.8 %. The overall mesh infection rate was 2.4 %. The recurrence rate was similar in patients in whom the mesh was implanted on the fascia (onlay), preperitoneally behind the rectus muscle, or intraperitoneally, although the onlay position tended to have a higher recurrence rate. The preperitoneal, retromuscular, or intraperitoneal positions of meshes are biomechanically more attractive and therefore favored by most surgeons. In the review of Hansson et al. [4], it was found that the modified Sugarbaker technique had the best results with respect to recurrence rate. In 1985, Sugarbaker described his technique for parastomal hernia repair [5]. Via a laparotomy, the trephine opening is covered with an intraperitoneally placed prosthetic mesh that is sutured to the fascial edge. The bowel is lateralized, passing from the hernia sac between the abdominal wall and the prosthesis into the peritoneal cavity. As we have learned from incisional hernia repair, an overlap of 35 cm between the mesh and the adjacent fascia is mandatory to prevent recurrent hernias [6]. Therefore, the Sugarbaker technique was modified around the trephine opening to guarantee an adequate overlap between the mesh and the fascia (Figs. 1, 2). Laparoscopic repair of an incisional hernia is favored by many surgeons because of a low infection rate of 0.7 % [7]. Meta-analysis of all randomized controlled trials performed by Forbes et al. [8] showed significantly lower wound and mesh infection rates in the laparoscopic group. Another potential advantage of the laparoscopic approach is that concomitant Fig. 1 Laparoscopic Sugarbaker technique incisional hernias can be detected and repaired at the same time. In a recent meta-analysis [4], the recurrence rate of the laparoscopic Sugarbaker repair was found to be 11.6 % (95 % CI = 6.418.0) in a group of 110 patients from six studies. Berger et al. [9] reported on the use of a sandwich technique that combines the Sugarbaker and keyhole techniques. After a median follow-up of 20 (range = 648) months, one of 47 (2.1 %) patients had a recurrent hernia. Recently, Mizrahi et al. [10] published data on the keyhole technique similar to that of Hansson et al. [4] published previously. Recurrences up to 46.4 % were reported by Mizrahi et al. The aim of the present study was to determine the results of the laparoscopically performed Sugarbaker technique for the repair of parastomal hernias done at four European centers with extensive experience in laparoscopy and laparoscopic hernia repair. Patients and methods A retrospective multicenter study was performed to determine the results of laparoscopic repair of parastomal hernias via a modified Sugarbaker technique. All consecutive patients who were operated on in the four participating centers between May 2005 and June 2010 were included in the study. The following data were extracted from the records: age, BMI, size of defect, comorbidities, ASA score, indication for surgery, technical details of the operation [i.e., adhesion score; size of the trephine opening, calculated as the area of an ellipse using the formula p 9 (0.5 9 length) 9 (0.5 9 width), intraoperative complications, and operating time], postoperative mortality and morbidity, duration of follow-up, and the presence of a recurrent hernia. Ad (...truncated)