Preventing Parastomal Hernia Using a Modified Sugarbaker Technique With Composite Mesh During Laparoscopic Abdominoperineal Resection

A Randomized Controlled Trial

Manuel López-Cano, MD; Xavier Serra-Aracil, MD; Laura Mora, MD; José Luis Sánchez-García, MD; Luis Miguel Jiménez-Gómez, MD; Marc Martí, MD; Francesc Vallribera, MD; Domenico Fraccalvieri, MD; Anna Serracant, MD; Esther Kreisler, MD; Sebastiano Biondo, MD; Eloy Espín, MD; Salvador Navarro-Soto, MD; Manuel Armengol-Carrasco, MD

Disclosures

Annals of Surgery. 2016;264(6):923-928. 

In This Article

Abstract and Introduction

Abstract

Objective: The aim of this study was to assess the reduction in the incidence of parastomal hernia (PH) after placement of prophylactic synthetic mesh using a modified Sugarbaker technique when a permanent end-colostomy is needed.

Summary of Background Data: Prevention of PH formation is crucial given the high prevalence of PH and difficulties in the surgical repair of PH.

Methods: A randomized, prospective, double-blind, and controlled trial. Rectal cancer patients undergoing laparoscopic abdominoperineal resection with permanent colostomy were randomized (1 : 1) to the mesh and nonmesh arms. In the mesh group, a large-pore lightweight composite mesh was placed in the intraperitoneal/onlay fashion using a modified Sugarbaker technique. PH was detected by computed tomography (CT) after a minimum follow-up of 12 months. Analysis was per-protocol.

Results: The mesh group included 24 patients and the control group 28. Preoperative data, surgical time, and postoperative morbidity were similar. The median follow-up was 26 months. After CT examination, 6 of 24 PHs (25%) were observed in the mesh group compared with 18 of 28 (64.3%) in the nonmesh group (odds ratio 0.39, 95% confidence interval 0.18–0.82; P = 0.005). The Kaplan-Meier curves showed significant differences in favor of the mesh group (long-rank = 4.21, P = 0.04). The number needed to treat was 2.5, which confirmed the effectiveness of the intervention.

Conclusions: Placement of a prosthetic mesh by the laparoscopic approach following the modified Sugarbaker technique is safe and effective in the prevention of PH, reducing significantly the incidence of PH.

Introduction

Prevention of parastomal hernia (PH) is an important objective when a permanent abdominal wall stoma is necessary. The usefulness of prophylactic mesh insertion (prosthetic or biologic) at the time of stoma construction during an open procedure has been assessed in various randomized controlled clinical trials.[1–5] Placement of the mesh in a sublay position (preperitoneal and/or retromuscular) using a keyhole technique has been shown to be effective in reducing the rate of PH in all[1–4] but one trial, in which the use of a noncross-linked porcine-derived acellular dermal matrix as a reinforcing material did not significantly reduce the incidence of PH formation.[5] For the laparoscopic approach, reinforcement of stomas with a mesh in the intraperitoneal onlay position also using the keyhole technique has been evaluated in 2 randomized trials.[6,7] In 1 study, a decrease in the incidence of PH was found, but the overall rate of PH in the mesh group (50%) was surprisingly high,[6] whereas in the other, the overall risk of radiologically detected PH in the mesh arm was not significantly reduced.[7]

The disappointing results of previous studies suggest that the keyhole mesh could be a nonoptimal solution for the prevention of the PH, because herniation of the contents of the abdominal cavity can still occur through the hole of the mesh and stretched aperture in the abdominal wall.[7,8] Also, this approach does not take into account that shrinkage of the prosthetic material with time may affect size and integrity of the trephine opening.[5,7] The modified Sugarbaker technique has been used in the repair of PH and has no hole in the mesh, but rather the defect in the abdominal wall is covered with an intraperitoneally placed prosthetic mesh.[9] The bowel is lateralized, passing between the abdominal wall and the prosthesis into the peritoneal cavity. An overlap of 3 to 5 cm between the mesh and the adjacent fascia is required to prevent recurrent hernias.[10] In the systematic review of Hansson et al,[11] the modified Sugarbaker technique was superior to the keyhole technique showing fewer recurrences. However, further studies are needed to assess the value of the modified Sugarbaker technique in the prevention of PH.[6,12] In addition, a specially designed mesh made of polyvinylidene fluoride with a central whole and a funnel arising (Dynamesh IPST) prophylactically implanted using an intraperitoneal onlay technique was also a safe and effective procedure preventing stoma complications.[13]

However, there are no specific recommendations about what is the rationale of the optimal technique to be used for prosthetic mesh reinforcement of the stoma to prevent PH and the impact in clinical practice. In fact, the effectiveness of a prophylactic mesh placed using a modified Sugarbaker technique during laparoscopic abdominoperineal resection (APR) for rectal cancer to prevent PH has not been previously evaluated.

We hypothesized that placement of a prophylactic large-pore lightweight and composite mesh using a modified Sugarbaker technique during laparoscopic APR in patients with rectal cancer undergoing permanent end-colostomy would reduce the incidence of PH. The objective was to assess the reduction in the incidence of PH after their placement.

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