Robotic Endoscopic Preperitoneal Paraostomal Hernia Repair (ePauli) for treatment of paraostomal hernia: Surgical technique—A video vignette

摘要

The approach to parastomal hernia currently represents a challenge for the surgeon given the lack of existing evidence in this field. These limitations range from diagnosis to classification as well as treatment. The European Hernia Society (EHS), as a world reference for the management of the abdominal wall, has shown increasing interest in this pathology and has made recommendations about its therapeutic management. Thus, the EHS has developed a classification based on two variables: the size of the hernial orifice and the existence of a concomitant incisional hernia. On the other hand, they establish that in the case of permanent colostomies the placement of prophylactic meshes significantly reduces the risk of parastomal hernia. Furthermore, the EHS advocates that in the case of minimally invasive repairs the use of meshes without holes is superior to those with holes (i.e. keyhole mesh). We present the case of a patient undergoing LAR (Low anterior Resection) surgery with a definitive terminal colostomy located on the left flank, and without the possibility of reconstruction, who developed a type I parastomal hernia (EHS classification). The patient presented with discomfort and pain related to the hernia, which is why surgical intervention was chosen (Video 1). It was decided to carry out a robotic approach, performing a Pauli-type hernioplasty with a 30 × 30 Prohosa mesh cut to 23 cm × 14 cm. First, the hernial contents were reduced and the stoma was skeletonized. Subsequently, the left posterior rectus sheath was opened with dissection of the left retrorectal plane. This is followed by a left transversus abdominis release (TAR), down-to-up, and an up-to-down TAR with union in the retro-ostomal area. Finally, the stoma was parietalized and lateralized and the peritoneal defect was closed, placing the mesh at the retromuscular level and removing the flap. Pauli-type repair of the parastomal hernia exposed in this case appears to be a good alternative based on the principles of biomechanics and abdominal wall reconstruction. However, comparative clinical trials with medium- to long-term follow-up are necessary to evaluate the results of both this surgical technique and the other surgical approaches. The main difference with respect to the ePauli technique is the robotic approach (although the ePauli could be done with this approach) as well as the advantage of transabdominal access, which in the case of paraostomal hernias is important due to loop management. The advantages of the transabdominal approach are: better control of the contents of the sac and the abdominal cavity; less retromuscular/preperitoneal dissection, since we limit ourselves only to the mesh overlap area; and a more versatile technique regardless of the location of the defect and the intraoperative findings. Francisco José Almoguera González: Conceptualization; investigation; writing – original draft; methodology; validation; writing – review and editing. Francisco Javier Espada Fuentes: Conceptualization; investigation. Luis Tallón Aguilar: Conceptualization; methodology; writing – review and editing. Francisco Moreno Suero: Conceptualization; writing – review and editing. José Tinoco González: Conceptualization; writing – review and editing. Salvador Morales Conde: Conceptualization; methodology; supervision. Eduardo Parra-Dávila: Conceptualization; methodology; supervision. No funding was required for this study. None declared. All data collected in this study will be processed anonymously in accordance with current confidentiality and data protection regulations, ensuring the protection of personal data according to Regulation (EU) No. 2016/679 of the European Parliament and of the Council of 27 April 2016 on Data Protection (GDPR), respecting the codes and standards of good clinical practice and guaranteeing patients' rights, as well as basic ethical principles (Declaration of Helsinki approved by the World Medical Assembly in its 2013 Fortaleza v