Parastomal hernias successfully repaired using a modified components separation method: two case reports

Abstract

Introduction: Parastomal hernia is a frequent complication after enterostomy formation. A repair using prosthetic mesh by way of a laparoscopic or open transabdominal approach is usually recommended, however, other procedures may be done if the repair is to be performed in a contaminated environment or when the abdominal cavity of the patient is difficult to enter due to postsurgical dense adhesion. The components separation method, which was introduced for non-transabdominal and non-prosthetic ventral hernia repair, solves such problems.

Case presentation: Case 1. A 79-year-old Japanese woman who underwent total cystectomy with ileal conduit for bladder cancer presented with a parastomal hernia, which was repaired using a keyhole technique. Simultaneously, an incisional hernia in the midline was repaired with a prosthetic mesh. One year after her hernia surgery, a recurrence occurred lateral to the stoma, but it was believed to be difficult to enter the peritoneal cavity because of the wide placement of mesh. Therefore, surgery using the components separation method was performed.

Conclusion: The components separation method is a novel and effective technique for parastomal hernia repair, especially in cases following abdominal polysurgery or midline incisional hernia repairs using large pieces of mesh. To the best of our knowledge, this is the first report in English on the application of the components separation method for parastomal hernia repair.

Figure 1

Preoperative computed tomography image of case 1. The transverse colon is protruding into the hernia sac lateral to the ileal conduit. A prosthetic mesh (arrow) previously used for a midline incisional hernia is visualized.

Figure 2

Operative technique for case 1 (1). Indigo carmine solution is injected into the ileal conduit, making the boundaries of the hernia sac clear.

Figure 3

Operative technique for case 1 (2). Relaxing incisions (arrow) are made on the anterior sheath of the rectus abdominis muscle and the external oblique aponeurosis, allowing the hernia orifice to be closed without tension.

Figure 4

Schematic explanation of the operative technique for case 1. Bold arrows indicate the direction of the fascial mobilization.

Figure 5

Preoperative computed tomography image of case 2. The redundant sigmoid colon is protruding from the stoma's lateral aspect into the hernia sac. A prosthetic mesh (arrow) previously placed for the midline incisional hernia is visualized.

Figure 6

Operative technique for case 2 (1). The colon is identified by palpation in continuity with the stoma limb inside the hernia sac on the lateral aspect of the stoma.

Figure 7

Operative technique for case 2 (2). A longitudinal incision (arrow) is made on the external oblique aponeurosis, and the fascia is slid medially.

Figure 8

Operative technique for case 2 (3). The hernia orifice is closed without tension.