**5.2 Laparoscopic repair**

Parastomal hernia repair with prosthetic mesh is recommended, since recurrence rates are unsatisfactory high after suture repair or relocation of the stoma. Complications that can arise with mesh placement for parastomal hernia are mesh-infection, fistula formation and adhesion formation. Laparoscopic repair is effective in correction of these hernias and has the advantages of improved vision and definition of the fascial edges of the hernia.

Laparoscopic techniques for repair of parastomal hernia with prosthetic mesh can be divided in 'keyhole techniques' and modified 'Sugarbaker techniques'. All involve introduction of trocars, extensive adhesiolysis, and identifying and measuring the fascial

The reported failure following laparoscopic Nissen fundoplication for GERD and paraesophageal hernia is between 2-33%. Although failure of fundoplication is unusual when performed by an experienced surgeon, wrap herniation ('slipped Nissen') is the most common mechanism of failure. Other causes of failure are represented by disrupted fundoplication, slipped fundoplication, crural stenosis, too tight wrap, misplaced fundoplication or twisted fundoplication. In carefully selected patients who have recurrent or persistent symptoms (heartburn, dysphagia, chest pain, regurgitation, asthma, hoarsness or laryngitis) after laparoscopic or open fundoplication a laparoscopic redo fundoplication can be safely performed by an experienced surgeon. The overall conversion rate of redo laparoscopic fundoplication is 10%. Complications occur in approximately 15%, slightly increasing with multiple redos. After redo laparoscopic fundoplication 70% of patients is

Occurrence of parastomal herniation is a common complication after stoma formation. The reported incidence of parastomal hernias varies from 28% in ileostomies to 56% in colostomies (Carne et al., 2003; LeBlanc et al., 2005; Rieger et al., 2004). A parastomal hernia is more likely to occur when the stoma emerges through the semilunar line rather than the rectus sheath. Although most hernias become present within two years after stoma

Perstomal type: bowel prolapsing through a circumferential hernia sac enclosing the

Parastomal hernia repair with prosthetic mesh is recommended, since recurrence rates are unsatisfactory high after suture repair or relocation of the stoma. Complications that can arise with mesh placement for parastomal hernia are mesh-infection, fistula formation and adhesion formation. Laparoscopic repair is effective in correction of these hernias and has

Laparoscopic techniques for repair of parastomal hernia with prosthetic mesh can be divided in 'keyhole techniques' and modified 'Sugarbaker techniques'. All involve introduction of trocars, extensive adhesiolysis, and identifying and measuring the fascial

 Intrastomal: hernia sac between the intestinal wall and the everted intestinal layer Symptoms patients may experience are pain, poor fitting of stoma-material resulting in leakage of stomal contents, obstruction, incarceration and cosmetic disfigurement. Fortunately, most parastomal hernias can be treated conservatively and surgical intervention is only indicated in 15% of patients with parastomal hernias (Hansson et al., 2003). Recurrence rates after surgical repair are reported up to 76%, and can be explained by

the underlying defect in wound healing and collagen metabolism in most patients.

the advantages of improved vision and definition of the fascial edges of the hernia.

**4.3 Treatment of recurrence** 

**5. Parastomal hernia** 

**5.1 Classification** 

stoma

**5.2 Laparoscopic repair** 

GERD-related symptom free (Smith et al., 2005).

construction, the risk of herniation extends up to 20 years.

Interstitial type: hernia sac within the aponeurotic layers of the abdomen

Parastomal hernias can be classified in four types: Subcutaneous type: subcutaneous hernia sac

defect. A mesh should provide at least 5 cm of overlap of the fascial edges and should be secured with tacks or constructed with transfascial sutures.

Several different 'keyhole techniques' have been described, which have in common that a mesh is placed with a central hole or slit in the mesh to allow the bowel to pass through the mesh to the stoma site. One of the main drawbacks is shrinkage of the mesh that can result in obstruction or recurrent herniation by enlargement of the hole. In the modified Sugarbaker technique no hole is made in the mesh but the bowel to the stoma is lateralized and covered by the mesh (Berger & Bientzle, 2007; Mancini et al., 2007; Sugarbaker, 1985). The mesh is secured to the abdominal wall at the margin of the mesh at 5 cm intervals. A second row of tackers is placed at the margin of the hernia defect with additional tackers at each side of the colon. Both techniques are promising, however long term results are not yet available. Perhaps prevention of development of parastomal hernia by placement of a lightweight sublay mesh is the key (Janes et al., 2004).
