Bladder cancer ranks as the ninth most frequently-diagnosed cancer worldwide, and Bricker surgery is an important procedure for treating it[10]. Parastomal hernia (PH) following radical cystectomy and ileal conduit(IC) remains a common complication, and occur in approximately 30% of patients [1, 2]. PH affects the appearance of the abdominal wall, causing discomfort, bloating, and intermittent pain around the stoma. It also impacts the function of the stoma and can lead to more severe issues such as incarceration. The treatment of PH include hernia support appliances, weight loss, avoidance of heavy lifting, patient education and surgery[6, 11]. Surgical management of PH following IC is challenging, with a high risk of recurrence and complications. The surgical approach for repairing PH following IC is similar to paracostomy hernia, including suture repair, re-siting and mesh repair. The suture repair has been gradually abandoned due to its high recurrence rate up to 50%[7, 12]. Stoma relocation and redo repair are difficult due to the limited length and displacement of the ureter, as well as the potential complications of incisional hernia and new parastomal hernia[6, 7, 13].Mesh repair, performed by open, laparoscopic or robotic approaches, remains the primary choice[5, 13, 14]. It is widely accepted that laparoscopic repair is superior to open repair in terms of operative time, length of hospital stay, postoperative complications, and recurrence rate for colostomy-related hernia repair[6, 7].
The European Guidelines for Parastomal Hernia Treatment recommends the Sugarbaker technique based on its lower recurrence rate than the Keyhole technique for colostomy-related hernia repair. But previous reports of the keyhole and Sugarbaker techniques regarding ileal conduit parastomal hernias are few and there were more reports about Keyhole repair than the Sugarbaker[5, 6, 15–18].Some surgeon concerned the Sugarbaker repair was not feasible for ileal conduits due to the length of the conduit and torsion of the anastomosed ureter by the mesh[2, 17].But we think laparoscopic Sugarbaker technique is highly suitable for repairing PH following IC and there are several important recommendations for the surgeon:
1) Preoperative bowel preparation and prophylactic antibiotics. Preoperative bowel preparation and prophylactic antibiotics is crucial to prevent postoperative infections. A clean bowel can minimize the contamination of intestines damage during adhesion separation.
2) safe adhesion separation poses a challenge and requires careful manipulation. There are numerous small bowel adhesions to the lower abdomen due to the radical cystectomy and pelvic lymph node dissection of the previous surgery. During adhesion separation, we placed a Foley catheter helping us identify the conduit bowel and the bilateral ureters. Exposing the ureter can be challenging. The right ureter generally has minimal anatomical displacement and the left ureter may be partially exposed in the abdominal cavity as it needs to be pulled to the right side for anastomosis with the intestinal tract. The site where both ureters join the enterostomy is located far from the enterostomy end. Surgeons should be cautious not to damage the ureter when dealing with adhesions related to the enterostomy. As long as an adequately covered intestinal segment is freed, it is not necessary to overly pursue the complete mobilization of the enterostomy segment. It is crucial to identify the mesenteric structures based on the location of the enterostomy, because the blood vessels that supply the intestines within the mesentery are unique. By carefully identifying the enterostomy and its mesenteric structures, damage to the enterostomy and its blood supply can be minimized during adhesion separation. It is preferable to use scissors for separation to avoid thermal damage from ultrasonic or electric knives. In this study, three patients experienced multiple bowel injuries which can not repaired under laparoscopy, leading to open conversion for thorough examination and repair before the laparoscopic procedure for Sugarbaker repair. But it doesn't affect the outcome of the surgery.
3) close the defect using unabsorbable stitches. There are multiple ways to close the defect. Our approach is using a laparoscopic hernia needle grasper ensuring that the puncture site is outside the area where the stoma bag is attached to avoid contamination or interference. We can also perform the closure under laparoscopy using unabsorbable barbed stitching. We recommend using unabsorbable barbed stitching because there is higher tension in pneumoperitoneum state and barbed stitch can help achieve a better closure for certain defects.
4) Use a large enough patch. We recommend using a composite patch that is large enough to cover approximately 6cm of the intestinal tube and extend at least 3cm beyond the edges of the defect[19, 20]. Some surgeons consider the use of slow resorbing mesh in order to theoretically reduce the risks of intestinal complication, digestive fstula, or bowel obstructions[21]. But we still use unabsorbable synthetic patch and In our study, there were no long-term complications related to mesh placement following IC PH repair. The patch can be secured using spiral tacks, starting with fixing the edges of the intestinal tube and gradually moving outward to secure and flatten the patch.
Although there were more reports about Keyhole repair, more and more surgeons recommend Sugarbaker in recent years[5, 21].The intestine covered by the mesh is just related to urinary function instead of defecation and there is less passive dilation and peristalsis Comparing to para-colostomy hernia. This may explain the lower recurrence rate of the Sugarbaker technique in PH following IC than para-colostomy hernia.
In this case study, three patients presented with a recurrence (8.6%), but they refused further surgery because the recurrence did not have significant impact on the quality of life. Many patients could be managed through nonoperative treatments[21].Two patients developed a peristomal abscess and one patient experienced partial intestinal obstruction, and they were all relieved through non-surgical treatment. This is the largest study report so far, with a maximum of 10 cases reported about Sugarbaker technique in PH following IC before[5, 21] and our study established that the Sugarbaker technique was associated with low complication and recurrence rate.
However, it is important to note that this study has certain limitations. Firstly, it is a retrospective study conducted at a single center, which may introduce bias. Additionally, there was no control group included in this study, as none of the patients underwent open repair or laparoscopic repair using alternative methods. As a result, no statistical analyses could be performed. It is recommended that international studies and registries be conducted to compare different repair methods for PH following IC, given its relative rarity.