Current state of laparoscopic parastomal hernia repair: A meta-analysis

Abstract

Aim: To evaluate the efficacy and safety of the laparoscopic approaches for parastomal hernia repair reported in the literature.

Methods: A systematic review of PubMed and MEDLINE databases was conducted using various combination of the following keywords: stoma repair, laparoscopic, parastomal, and hernia. Case reports, studies with less than 5 patients, and articles not written in English were excluded. Eligible studies were further scrutinized with the 2011 levels of evidence from the Oxford Centre for Evidence-Based Medicine. Two authors reviewed and analyzed each study. If there was any discrepancy between scores, the study in question was referred to another author. A meta -analysis was performed using both random and fixed-effect models. Publication bias was evaluated using Begg's funnel plot and Egger's regression test. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications. Studies were grouped by operative technique where indicated. Except for recurrence, most postoperative morbidities were reported for the overall cohort and not by approach so they were analyzed across approach.

Results: Fifteen articles with a total of 469 patients were deemed eligible for review. Most postoperative morbidities were reported for the overall cohort, and not by approach. The overall postoperative morbidity rate was 1.8% (95%CI: 0.8-3.2), and there was no difference between techniques. The most common postoperative complication was surgical site infection, which was seen in 3.8% (95%CI: 2.3-5.7). Infected mesh was observed in 1.7% (95%CI: 0.7-3.1), and obstruction requiring reoperation also occurred in 1.7% (95%CI: 0.7-3.0). Other complications such as ileus, pneumonia, or urinary tract infection were noted in 16.6% (95%CI: 11.9-22.1). Eighty-one recurrences were reported overall for a recurrence rate of 17.4% (95%CI: 9.5-26.9). The recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, whereas the recurrence rate was 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

Conclusion: Laparoscopic intraperitoneal mesh repair is safe and effective for treating parastomal hernia. A modified Sugarbaker approach appears to provide the best outcomes.

Keywords: Colostomy; Hernia; Ileostomy; Keyhole; Laparoscopic; Parastomal; Repair; Sandwich; Sugarbaker; Treatment.

Figure 1

Flow-chart of screening criteria.

Figure 2

Meta-analysis of proportion of overall complications for all techniques (random effects model; I² = 69.9%, P < 0.001; Egger’s Bias = 3.13, P = 0.003). The square size represents the weight of the study, and the horizontal lines represent the 95%CI of the effect estimate.

Figure 3

Meta-analysis of proportion of recurrences of Sugarbaker (random effects model; I² = 58.1%, P = 0.020; Egger’s Bias = 1.92, P = 0.068). The square size represents the weight of the study, and the horizontal lines represent the 95%CI of the effect estimate.

Figure 4

Meta-analysis of proportion of recurrences of Keyhole (random effects model; I² = 87.4%, P < 0.001; Egger’s Bias = 3.10, P = 0.025). The square size represents the weight of the study, and the horizontal lines represent the 95%CI of the effect estimate.