Unusual and Difficult Hernias in the Obese Population: Suprapubic and Parastomal

The Hole in the Wall with Samuel Szomstein, MD, FACS

This Month’s Topic: Unusual and Difficult Hernias in the Obese Population:
Suprapubic and Parastomal

This Month’s Featured Experts: Jonathan Slone, MD, MBA, MPH, and Karan Bath, MD

Clinical Fellows, the Bariatric Institute and Section of Minimally Invasive Surgery, Cleveland Clinic, Weston, Florida

Bariatric Times. 2012;9(1):18–20

A Message from Column Editor Samuel Szomstein, MD, FACS

Dear Readers of Bariatric Times:
I would like to wish you a Happy New Year and welcome you to this fifth installment of “The Hole in the Wall.” I am very proud to present Drs. Jonathan Sloan and Karan Bath, two of my current clinical fellows at the Bariatric and Metabolic Institute and Division of Minimally Invasive Surgery at Cleveland Clinic Florida, who have done a nice and concise review of some of the very unusual and difficult hernias we might encounter in the obese population. Here, they offer some tips and strategies in their management.
Once again, welcome to “The Hole in the Wall.” We hope you will enjoy this column and we look forward to your questions, comments, and participation in future issues.

Sincerely,

Samuel Szomstein, MD, FACS, Associate Director of the Bariatric Institute and Section of Minimally Invasive Surgery at the Cleveland Clinic in Weston, Florida, and Clinical Associate Professor of Surgery, Florida International University

Part 1: Management of Suprapubic Hernias in the Obese Population
by Karan Bath, MD

Introduction
Ventral hernias are commonly seen by surgeons in the present practice. Bariatric surgeons may be faced with these before, during, and after bariatric procedures. About eight percent of bariatric patients undergoing surgery have previously known ventral hernias.[1] Morbid obesity can make these repairs quite challenging. Suprapubic hernias, considered a subset of ventral hernia, are relatively rare. Here, we provide a review of the literature and different techniques described to approach these uncommon hernias.

Suprapubic hernias are used to describe those defects that are located above the symphysis pubis. Most suprapubic hernias are secondary to prior incisions, most commonly low midline—Pfannenstiel, Maylard, and Cherney—incisions generally used for urological or gynecological procedures.[2,3] These hernias have also been reported after suprapubic catheter placement.[4–6] This hernia results from the disruption of the musculotendinous elements of the abdominal wall as they insert into the pubis. This disruption is brought about by either the destruction of these musculotendinous tissues at their lower end or the resection of portions of the pubic bone.[2]

Preoperative considerations
Suprapubic hernias present a unique and technically difficult challenge, more so in the obese population.[12] Deferring hernia repair in the patient with morbid obesity until after bariatric surgery has its advantages, but consideration has to be given to the hernia itself. Smaller defects have a greater tendency to cause complications, which after bariatric surgery, can be disastrous. Due to this, the surgeon has to decide on the timing of the hernia repair. Preoperative workup should include a thorough medical and surgical history, especially prior hernia repairs. Physical exam should include attempts to delineate the inferior edge of the hernia in relation to the symphysis pubis. Radiologic studies will further aid in delineating the hernia defect, contents of the sac, and the proximity to the symphysis pubis, which may determine the management of the hernia.[7]

Operative considerations
There is limited experience in the repair of suprapubic hernias, both open and laparoscopic. Suprapubic hernia repair is frequently a technically difficult procedure, even more so in the bariatric population. This is often due to extensive adhesions from multiple previous operations, the necessary wide pelvic dissection, presence of a large pannus, and adequate mesh coverage. In addition, suprapubic hernias lead to longer operative times and need for extensive adheiolysis, particularly in the population with morbid obesity. Suprapubic hernias cannot possibly be corrected without the use of a prosthesis, and the use of prosthetic material has to be factored into the timing of the repair before, during, or after the bariatric procedure. Suprapubic hernias are considered difficult to repair due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder. There is a strong association in the literature between hernia recurrences and the lack of mesh fixation with full-thickness transabdominal sutures.[8, 9]

Open repair
Bendavid[2] reported the Shouldice Clinic experience repairing suprapubic hernias via an open technique. All the patients in the study presented with a denuded pubis lacking fascia. The defect was approached preperitoneally, and a polypropylene mesh was anchored to the pubis and Cooper’s ligaments inferiorly and full-thickness abdominal wall sutures superiorly. The results were favorable after a 5- to 48-month follow up with no infections or seromas. No mention of recurrences was made.[2]

Laparoscopic approach
Hirasa et al[11] reported the first laparoscopic experience with the repair of suprapubic hernias. A composite mesh with a 2 to 3cm overlap was fixated only with spiral tacks and no transabdominal sutures were placed. They had a hernia recurrence rate of 14.3 percent as a result of the mesh pulling off of the abdominal wall.[11]

Carbonell et al,[7] reported their series of 36 patients with laparoscopic repair of suprapubic hernias. The technique described was as follows: dissection into the space of Retzius to mobilize the dome of the bladder, intraperitoneal onlay of mesh using a barrier mesh, careful tack fixation to the pubic bone and Cooper’s ligaments, and extensive transfascial suture fixation of the mesh. Overall recurrence rate was 5.5 percent. Recurrences were not observed when multiple suture were applied directly to the pubis and Cooper’s ligament.[7]

Conclusions
Suprapubic hernias are difficult to manage secondary to the location, adjacent structures, and complexity of the repair. The technique requires adequate overlap of the mesh, fixation to the Cooper’s ligaments and pubis, and the use of full thickness transabdominal sutures. In addition, the laparoscopic approach has been shown to be safe and effective for repair of these difficult hernias. There is a lack of adequate literature on the subject, especially in regards to the obese population. Most of the conclusions are made in regards to patients with average body mass index (BMI), and it can be safely stated that in patients with morbid obesity, the difficulty of the procedure and the complication rate would be higher.

Figure 1

Figure 2

Part 2: Management of Parastomal Hernias in the Obese Population

by Jonathan Slone, MD, MBA, MPH

Introduction
Approximately 120,000 to 130,000 stomas will be created in the United States annually. With the alarming increase in the rate of obesity in America, caregivers will frequently encounter the complex nature of creating stomas and managing complications, such as parastomal hernias. The following is a review of preoperative, operative, and preventive measures in the literature regarding parastomal hernias.

Preoperative
A number of factors must be taken into consideration prior to the creation of stoma. Preoperative counseling should always be performed to help with educating the patient in regards to the need for the stoma and its benefits. It also helps to alleviate personal fears of bad hygiene, limitation in social or athletic activities, and elimination of intimacy. An enterostomal therapist is helpful to provide information regarding the management of appliances and the general management of the enterostomy.
Optimal site selection is crucial. The proposed site should be evaluated with the patient in supine, sitting, and standing positions. Optimally, the stoma should be placed at the superior apex of the infraumbilical fat fold in the lower quadrant, in the center of the “ostomy trianglem,” which is bounded by the superior iliac spine, the pubic tubercle, and the umbilicus. This may be a challenge in the patient with morbid obesity due to body habitus. Abdominal wall thickness is much less above the umbilicus than below. Thus, the chosen site may be augmented avoiding scars, bony prominences, and skin creases, ensuring a 6cm area of flat surface surrounding the stoma, and it should pass through the rectus muscle to reduce the risk of parastomal hernias.

Enterostomy Construction
The procedure starts with a 2cm diameter skin incision over the proposed site. The subcutaneous fat should be preserved as this will help to provide support and will reduce the risk of herniation. Once the rectus sheath is encountered, a cruciate incision is created followed by splitting the rectus muscle and entering the peritoneum. The aperature should allow two of the surgeon’s fingers to easily pass. If possible, the small bowel is preferred over large due to the smaller abdominal wall orifice, which will lessen the risk of herniation. The complication rate for colostomies and ileostomies have been 0 to 40 and 0 to 22 percent, respectively. Several techniques have been described for improving the success rate of stoma creation in the obesity. Maturation of the antimesenteric corner of the colon has been described when a short mesentery will not allow full reach without significant tension. Some use a penrose drain to encompass the bowel as it is being delivered to the skin surface in order to decrease resistance. Others have used the Alexis Wound Protector (Applied Medical, Rancho Santa Margarita, California) with good success and low rates of parastomal hernias.

Parastomal Hernias
By definition, a parastomal hernia is a defect in the abdominal wall that allows a portion of the alimentary tract to bulge outward. Fifty percent of parastomal hernias occur within one year of the operation. Obesity has been directly linked to increasing the risk of such hernias likely due to increased intrabdominal pressures and less robust tissues than in the patient population of normal weight. In addition, the radius of the abdomen leads to greater tangential forces being applied to the opening. Physical examination is an adequate means of detecting parastomal hernias. However, if one suspects a hernia but cannot identify it on examination, a computed tomography (CT) scan is an excellent means and has a sensitivity of approximately 78 percent. Repair of parastomal hernias should be mandate for symptomatic hernias to include incarceration, obstruction, strangulation, chronic pain, and leakage.
Techniques, such as laparoscopy, fascial fixation, and creation of an extraperitoneal path, have not statistically reduced the incidence of parastomal hernias. One technique that has shown some promise involves the use of a prophylactic mesh. The studies involving the use of mesh ranged from 2 to 68 months follow up and the incidence of recurrent hernia was less than 15 percent. In contaminated procedures, the use of biologic meshes, such as acellular dermal matrix, have shown good success rates with approximately 30-percent recurrence rates.

Several retrospective studies have reviewed outcomes comparing conventional parastomal repairs to include primary suture, stoma relocation, and mesh repairs with laparoscopic techniques. The outcomes failed to show statistical significance in surgical site infections, complications, or recurrences when comparing laparotomy to laparoscopy.

Prevention
The following are some preventive measures that have been employed with success of preventing parastomal hernias:
•    On discharge, patients should be advised to avoid all heavy lifting for three months following surgery.
•    Patients should be taught abdominal exercises and be advised to undertake these exercises daily for at least 12 months postoperatively. In addition, support belts and girdles should be measured and ordered for the patients and the caregiver should encourage the patient to wear these while lifting anything heavy or undertaking heavy work.
•    Patients should be monitored at regular intervals for one year postoperatively for the incidence of parastomal hernia.

Conclusion
Prevention of parastomal hernias in the population with obesity represents a complicated challenge and important goal when considering a permanent stoma. Although the literature fails to show statistical differences in techniques, some promising results have recently been published in regards to the use of intraperitoneal mesh.

References
1.    Datta T, Eid G, Nahmias, et al: Management of Ventral hernia during laparoscopic gastric bypass. Surg Obes Relat Dis. 2004;4(6):754-757
2.    Bendavid R. Incisional parapubic hernias. Surgery. 1990;108:898–901.
3.    Czapla J, Kosmalski S, Auriga N, Sankowski M. Complications of abdominal obstetric and gynecological operations with suprapubic incision by the Pfannenstiel method. Ginekol Pol. 1982;53(7-8):477–481.
4.    Lobel RW, Sand PK. Incisional hernia after suprapubic catheterization. Obstet Gynecol. 1997:89(Pt 2):844–846.
5.    Nabi G, Aron M, Gupta NP: Incisional hernia after supapubic trocar cystostomy. Urol Int. 2003;70(3):249–250.
6.    Mehta A, Makris A, Saad A, Callaghan PS. Incisional hernia after suprapubic catheter insertion. BJU Int. 1999;84(4):526–527.
7.    Carbonell A, Kercher K, Matthews B, Sing R, Cobb W, Heniford B. The laparoscopic repair of suprapubic ventral hernias. Surg Endosc. 2004;19 (2):174–177.
8.    Koehler RH, Voeller G. Recurrences in laparoscopic incisional herniarepairs: A personal series and review of the literature. JSLS. 1999;3(4):293–304.
9.    LeBlanc KA. The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg. 2001;67(8):809–812.
10.    Varnell B, Bachman S, Quick J, et al. Morbidity associated with laparoscopic repair of suprapubic hernias. Am J Surg. 2008;196(6):983–987; discussion 987–988.
11.    Hirasa T, Pickleman J, Shayani V. Laparoscopic repair of parapubichernia. Arch Surg. 2001;136(11):1314–1317.
12.    Jenkins ED, Yom VH, et al. Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study. Surg Endosc. 2010;24(8):1872–1877.
13.    De Raet J, Delvaux G, Haentjens P, Van Nieuwenhove Y. Waist circumference is an independent risk factor for the development of parastomal hernia after permanent colostomy. Dis Colon Rectum. 2008 ;51(12):1806–1809. Epub 2008 May 16.
14.    Meagher AP, Owen G, Gett R. An improved technique for end stoma creation in obese patients. Dis Colon Rectum. 2009;52(3):531–533.
15.    Williams NS, Nair R, Bhan C. Stapled mesh stoma reinforcement technique (SMART)—a procedure to prevent parastomal herniation. Ann R Coll Surg Engl. 2011;93(2):169
16.    Slater NJ, Hansson BM, Buyne OR, et al. Repair of parastomal hernias with biologic grafts: a systematic review. J Gastrointest Surg. 2011;15(7):1252–1258. Epub 2011 Mar 1. Review.
17.    Smart NJ, Velineni R, Khan D, Daniels IR. Parastomal hernia repair outcomes in relation to stoma site with diisocyanate cross-linked acellular porcine dermal collagen mesh. Hernia. 2011;15(4):433–437. Epub 2011 Jan 30.

Funding: No funding was provided in the preparation of this article.

Financial disclosures: Drs. Slone and Bath report no conflicts of interest relevant to the content of this article.

Category: Hole in the Wall, Past Articles