Parastomal hernia repair under Sandwich technique after previous Sugarbaker failure

A 69-year-old woman with no known drug allergies, with a prior medical history of hypertension, type 2 diabetes mellitus  and chronic kidney disease. Secondarily to a rectum neoplasia the patient underwent an abdominoperineal resection (Miles intervention) with a terminal colostomy. Subsequently she presented with a parastomal hernia at this level that was repaired using the Sugarbaker technique.

During the follow-up the patient presented with a recurrence of the parastomal hernia so it was decided to perform a repair using Sandwich technique, which combines the keyhole and Sugarbaker techniques.

Three ports were placed as follows: a 12-mm trocar on the right side of the umbilicus for a flexible laparoscope; a 12-mm trocar in the right subcostal region; and a 5-mm trocar in the right lower quadrant.

Careful adhesiolysis of the abdominal wall around the stoma was performed. A parastomal fascial gap was completely freed from the greater omentum and bowel loops, which protruded into the hernia sac. After identifying the parastomal hernia orifice, the stoma loop was completely dissected free from the peritoneal adhesion to become a straight line.

The size of the mesh was selected, large enough to exceed the hernia orifice by at least 5 cm in all directions. We used two titanium meshes: a (hole type) mesh incised to the center and a central band type.

The first mesh is inserted rolled in the abdominal cavity with two stitches to facilitate its placement. The hole type mesh was placed around the stoma to cover the parastomal hernia orifice using the keyhole technique. The mesh was fixed using absorbable tacks, with the incised parts of the mesh medially closed. Absorbable tacks were placed around the periphery of the mesh, approximately 1 cm apart. Then we cut the stitches that keep the mesh screwed to finish unfolding and complete its fixation using more absorbable tacks

Afterwards, a further mesh (central band type) was overlaid to cover the first mesh and the whole abdominal wall by the Sugarbaker technique. After fixing the second mesh using absorbable tacks, the stoma loop was placed between both meshes to facilitate the desired lateralization. Some space must be left around the stoma loop to avoid stricture by the mesh.

Finally we finished the surgery. The recurrent parastomal hernia was repaired using the Sandwich technique with two meshes implanted in an intraperitoneal onlay position.