Laparoscopic repair of parastomal hernia after laparoscopic radical cystectomy

Overview

Introduction:

Radical cystectomy for invasive urothelial carcinoma is a challenging procedure associated with a high risk of perioperative as well as postoperative complications. Parastomal hernia tends to be rather rare, but all the more serious. The patient is at risk of upper urinary tract obstruction with renal insufficiency, development of obstructive pyelonephritis or impaired bowel passage.

Methods:

Early August 2014, a 66-year-old man underwent laparoscopy-assisted radical cystectomy with prophylactic appendectomy and extracorporeal Bricker conduit construction. The procedure lasted 330 minutes, there were no complications, and blood loss was 150 mL. Histologically, it was pT2apN0(16/0)M0 urothelial carcinoma of the bladder; simultaneously, an incidentaloma was found: GS6 pT1aN0M0 prostate carcinoma. The early postoperative course was uneventful; on the 12th postoperative day, the patient was discharged to home care. Two years later, a solitary metastasis in the right lower lung field and a parastomal hernia containing bowel loops were detected. Atypical wedge resection of the right lower lung lobe was performed in the middle of December 2016. Histology showed a metastasis of urothelial carcinoma. After restaging, the oncologist chose not to administer chemotherapy because of absence of detectable disease. The patient was followed up for two years after the procedure, and since no recurrence of the primary disease was found, he was indicated to laparoscopic repair of parastomal hernia. The procedure was started with introduction of a capnoperitoneum in the medioclavicular line in the left hypochondrium. Under visual control, two other ports were placed in the anterior axillary line at the level of the umbilicus and in the hypogastrium. First, omental and bowel loop adhesions were broken down in addition to the original minilaparotomy. Next, adherent loops were removed from the parastomal hernia and the conduit was released. Parietex© hernia mesh was placed in the abdominal wall around the conduit and secured with Securastrap© staples.

Results:

There were no complications during the procedure, it lasted 90 minutes, and blood loss was negligible. The postoperative condition required no ICU stay; since postoperative day 1, mobilization and switching to solid food was initiated. On postoperative day 3, the catheter was removed from the ostomy site and, after bowel passage had been restored, the patient was discharged to home care on postoperative day 5.

Conclusion:

Laparoscopic approach appears to be a suitable alternative for the management of parastomal hernia with Bricker conduit.

KEY WORDS

Ureteroileostomy, parastomal hernia, laparoscopic correction.