Tratamiento laparoscópica de la hernia paraostomal: En búsqueda de una nueva técnica / Laparoscopic repair of parastomal hernia: Searching for a new technique

Introducción: La hernia paraostomal es una complicación frecuente de los pacientes ostomizados. Se presenta en más del 50% de los casos, sin embargo, solo del 10 al 15% son sintomáticas y requieren tratamiento quirúrgico. Objetivo: Describir y analizar una técnica laparoscópica en la que combinamos la reparación anatómica con la colocación de una malla protésica. Material y Método: Se realizó un estudio retrospectivo de una base de datos diseñada en forma prospectiva del servicio de cirugía general del "The Western Pennsylvania Hospital". El período analizado fue de Agosto de 2006 a Octubre de 2007. Se incluyen los procedimientos electivos y aquellos pacientes con hernias paraostomales sintomáticos. Las variables analizadas fueron edad, sexo, estadía hospitalaria, complicaciones intraoperatorias, postoperatorias y recidivas. Resultados: Entre agosto del 2006 y diciembre del 2007 se operaron 6 pacientes con hernias paraostomales sintomáticas. Tres de ellos tenían una amputación abdominoperineal por cáncer de recto; dos proctocolectomías por Enfermedad Inflamatoria Intestinal (Colitis ulcerosa y Crohn), y una colectomía subtotal debido a colitis fulminante secundario a infección por Clostridium Difficile. No se registraron conversiones ni complicaciones intraoperatorias. Un paciente evolucionó con íleo postoperatorio, que revirtió con tratamiento médico. La estadía media hospitalaria fue de 4 días (Rango: 2-7 días). El seguimiento postoperatorio promedio fue de 5,8 meses (rango 1-18 meses). No hubo recidivas. Conclusión: Proponemos una técnica diferente para la reparación de la hernia paraostomal. Además de reducir y disecar el saco herniario, disminuimos el espacio muerto suturando el área que rodea al ostoma a la fascia, con la intención de disminuir la formación de seroma y/o recurrencia.

Background: Parastomal hernia is a common complication of stoma formation that has been reported in more than 50% of patients on long term follows up. Most of them do not require repair; however 10 to 15% will become symptomatic and will need surgical repair. Objective: To describe and analyzed a laparoscopic technique that combines both tissue and mesh repair. Material and Methods: Retrospective review of a prospective collected data from The Western Pennsylvania Hospital. We include all patients who underwent this novel laparoscopic approach of the paraostomal hernia from August 2006 to October 2007 at the Western Pennsylvania Hospital. The surgeries were performed electively and in symptomatic parastomal hernia patients. Data collected included demographies, length of hospital stay, complications and recurrence. Results: We performed 6 laparoscopic parastomal hernia repairs. Three patients had APR due to rectal cancer; two had a proctocolectomy due to Inflammatory Bowel Disease (Ulcerative Colitis and Crohn); and one patient had a subtotal colectomy due to fulminant Clostridium Difficile colitis. There were no conversions to open surgery and no intraoperative complications. One patient developed a postoperative ileus that resolved with a no operative treatment. The mean hospital stay was 4 days (Range: 2 to 7 days). The mean follow up period was 5.8 months (Median 3 month; range: 1-18 month). All patients are asymptomatic and without hernia recurrence. Conclusion: We propose a novel laparoscopic approach to the parastomal hernia. In addition to reducing and dissecting the hernia sac, we reduce the dead space by suturing the area around the stoma to the fascia, thus possibly reducing the incidence of seroma and recurrence.

Experiência inicial no tratamento das hérnias paraestomais / Initial experience in the treatment of parastomal hernias

O surgimento da hérnia paraestomal é uma conseqüência direta da confecção do estoma. Apesar de todos os esforços empregados na sua prevenção, a freqüência é bastante elevada e aumenta com o tempo. As alternativas de cura dessa afecção são todas cirúrgicas e várias técnicas foram propostas. Nesse artigo apresentamos uma breve revisão das alternativas operatórias que já foram apresentadas e apresentamos a técnica que empregamos. Desenvolvemos uma abordagem por videolaparoscopia com a colocação de uma tela intraperitoneal denominada nó de gravata. Em nossa série de 17 pacientes observamos bons resultados sem nenhuma recidiva até o momento.

The parastomal hernia is a direct consequence of making the stoma. Although all the efforts used in its prevention, this condition is a frequent long-term complication that increases with time. Management of the hernia is always surgical and different techniques have been proposed. In this article, the authors present a brief revision of the surgical treatment and present their own technique. The defect is assessed by videolaparoscopy and correction is performed with an intraperitoneal mesh; we call this technique "tie knot". In our 17 patients' series, we observed good results and no recurrence until now.