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      Videosurgery and other Miniinvasive Techniques
      Termedia Publishing House

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          Abstract

          Editorial comments on the leading article: New minimally invasive technique of parastomal hernia repair – methods and review M. Szczepkowski, P. Skoneczny, A. Przywózka, P. Czyżewski, K. Bury Prof. Marek Szczepkowski is the head of the Department of General and Colorectal Surgery of Bielański Hospital in Warsaw, one of the most experienced surgical departments in parastomal hernia repair in Poland. Several surgical techniques of parastomal hernia repair have been described. Currently, the Sugarbaker technique, described in 1980, and the sandwich technique, which was first described by Berger, are the most common for surgical repair [1, 2]. The laparoscopic approach to parastomal hernia repair seems to be superior to the open approach due to its lower rate of recurrence and lower rate of postoperative complications, and this method was suggested by Hansson et al. [3]. Laparoscopy in other hernia repair regions has been advocated for many times by numerous surgeons, including in the pages of Videosurgery, and it was extremely encouraging that the Hybrid Operation was used by a team of Prof. Szczepkowski in parastomal hernia repair [4, 5]. Polish surgeons’ contribution to the development of this very difficult field of hernia repair surgery is very visible. The classification currently in force and suggested by the European Hernia Society (EHS) takes into account the experience of the center which is headed by Prof. Szczepkowski [6, 7]. From this center there have been published several papers concerning the experience of Bielański Hospital. During the consensus meeting on Parastomal Hernia Repair in Gdansk in 2011, the Working Group of Polish specialists in this domain was established. The goal of this group was to give a recommendation and the proper approach to this surgical problem, which is very difficult to resolve. This consensus was published in the Polish Journal of Surgery as a contribution to further discussion and studies and is still the indicator for many surgeons [8]. This original paper presents a prospective single center and single surgeon study which shows early results of the novel concept of the minimally invasive surgical technique of parastomal hernia repair – the HyPER technique (Hybrid Parastomal Endoscopic Re-do). It also contains a short review of the most popular methods of resolving this difficult surgical problem. This technique consists of three main parts: the initial, laparoscopic part (adhesiolysis of the region of the ostomy and hernia sac; the next part – open technique (excision of stoma and hernia sac, intraperitoneal placement of special, dedicated for parastomal hernia intraperitoneal on-lay mesh (IPOM) with a funnel and creation of a new stoma with narrowing of the hernia orifice); and the third part – a return to laparoscopy with fixation of this special mesh to the abdominal wall by tacks. According to the initial results this new technique is very promising because it combines the advantages of the open and laparoscopic approach. The authors believe that factors such as narrowing the fascia aperture and removal of the hernia sac have greatly attributed to reduction of the recurrence rate of parastomal hernia. Another important factor is adequate mesh selection. Nevertheless, further studies need to be conducted to confirm this thesis in the context of a large group of patients and long-term follow-up.

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          Surgical techniques for parastomal hernia repair: a systematic review of the literature.

          Parastomal hernias are a frequent complication of enterostomies that require surgical treatment in approximately half of patients. This systematic review aimed to evaluate and compare the safety and effectiveness of the surgical techniques available for parastomal hernia repair. Systematic review was performed in accordance with PRISMA. Assessment of methodological quality and selection of studies of parastomal hernia repair was done with a modified MINORS. Subgroups were formed for each surgical technique. Primary outcome was recurrence after at least 1-year follow-up. Secondary outcomes were mortality and postoperative morbidity. Outcomes were analyzed using weighted pooled proportions and logistic regression. Thirty studies were included with the majority retrospective. Suture repair resulted in a significantly increased recurrence rate when compared with mesh repair (odds ratio [OR] 8.9, 95% confidence interval [CI] 5.2-15.1; P < 0.0001). Recurrence rates for mesh repair ranged from 6.9% to 17% and did not differ significantly. In the laparoscopic repair group, the Sugarbaker technique had less recurrences than the keyhole technique (OR 2.3, 95% CI 1.2-4.6; P = 0.016). Morbidity did not differ between techniques. The overall rate of mesh infections was low (3%, 95% CI 2) and comparable for each type of mesh repair. Suture repair of parastomal hernia should be abandoned because of increased recurrence rates. The use of mesh in parastomal hernia repair significantly reduces recurrence rates and is safe with a low overall rate of mesh infection. In laparoscopic repair, the Sugarbaker technique is superior over the keyhole technique showing fewer recurrences.
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            European Hernia Society classification of parastomal hernias

            Purpose A classification of parastomal hernias (PH) is needed to compare different populations described in various trials and cohort studies, complete the previous inguinal and ventral hernia classifications of the European Hernia Society (EHS) and will be integrated into the EuraHS database (European Registry of Abdominal Wall Hernias). Methods Several members of the EHS board and invited experts gathered for 2 days to discuss the development of an EHS classification of PH. The discussions were based on a literature review and critical appraisal of existing classifications. Results The classification proposal is based on the PH defect size (small is ≤5 cm) and the presence of a concomitant incisional hernia (cIH). Four types were defined: Type I, small PH without cIH; Type II, small PH with cIH; Type III, large PH without cIH; and Type IV, large PH with cIH. In addition, the classification grid includes details about whether the hernia recurs after a previous PH repair or whether it is a primary PH. Clinical validation is needed in the future to assess if the classification allows us to differentiate the treatment strategy and if the classification impacts outcome in these different subgroups. Conclusion A classification of PH divided into subgroups according to size and cIH was formulated with the aim of improving the ability to compare different studies and their results.
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              Laparoscopic repair of parastomal hernias: a single surgeon's experience in 66 patients.

              The repair of parastomal hernias represents a surgical problem with high complication and failure rates. A basic principle is the necessity of mesh-based techniques. The study was performed to evaluate a laparoscopic approach, primarily based on the intraperitoneal on lay mesh technique. Sixty-six patients with a symptomatic parastomal hernia were enrolled in the prospective study between November 1999 and February 2006. After complete adhesiolysis, the mesh was introduced to cover the fascial defect of the hernia and the original midline incision. In special cases, a two-mesh technique was used. First, an incised mesh was placed around the stoma sling. The second mesh was used to cover the abdominal wall with the first mesh; the stoma sling was placed between the two meshes for at least 5 cm. The two-mesh technique proved to be superior in terms of recurrence rate especially in cases with a lateral fascial defect. The laparoscopic repair of parastomal hernias is a surgically challenging procedure with promising results when using the two-mesh technique. Therefore, two meshes should be used in all cases of parastomal hernias. Polyvinylidene fluoride was revealed to be the most suitable material for the sandwich repair in terms of possible ingrowth and infection resistance.
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                Author and article information

                Journal
                Wideochir Inne Tech Malo Inwazyjne
                Wideochir Inne Tech Malo Inwazyjne
                WIITM
                Videosurgery and other Miniinvasive Techniques
                Termedia Publishing House
                1895-4588
                2299-0054
                14 April 2015
                April 2015
                : 10
                : 1
                : 8-9
                Affiliations
                Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
                Author notes
                Address for correspondence: Prof. Tadeusz Wróblewski, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1 A Banacha St, 02-097 Warsaw, Poland. e-mail: t.wroblewski@ 123456videosurgeryjournal.com
                Article
                24879
                10.5114/wiitm.2015.50053
                4414114
                579fc474-4740-4b2d-8177-a91017e5021c
                Copyright © 2015 Sekcja Wideochirurgii TChP

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 15 January 2015
                : 15 January 2015
                : 15 January 2015
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                Surgery
                Surgery

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