Copyright © 2013, the Korean Surgical Society
J Korean Surg Soc 2013;84:371-376
Journal of the Korean Surgical Society
pISSN 2233-7903ㆍeISSN 2093-0488
Received September 11, 2012, Revised January 20, 2013, Accepted February 12, 2013
Correspondence to: Nam Kyu Kim
Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea
Tel: ＋82-2-2228-2105, Fax: ＋82-2-313-8289, E-mail: email@example.com
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
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Laparoscopic repair of parastomal and incisional
hernias with a modified Sugarbaker technique
Duck Hyoun Jeong, Min Geun Park1, George Melich2, Hyuk Hur, Byung Soh Min, Seung Hyuk
Baik, Nam Kyu Kim
Department of Surgery, Yonsei University College of Medicine, Seoul, 1Department of Surgery, Hallym University Chuncheon
Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea, 2Department of General Surgery, McGill
University, Montreal, QC, Canada
A parastomal hernia is the most common surgical complication following stoma formation. As the field of laparoscopic sur-
gery advances, different laparoscopic approaches to repair of parastomal hernias have been developed. Recently, the
Sugarbaker technique has been reported to have lower recurrence rates compared to keyhole techniques. As far as we know,
the Sugarbaker technique has not yet been performed in Korea. We herein present a case report of perhaps the first laparo-
scopic parastomal hernia repair with a modified Sugarbaker technique to be successfully carried out in Korea. A 79-year-old
woman, who underwent an abdominoperineal resection for an adenocarcinoma of the rectum 9 years ago, presented with a
large parastomal and incisional hernias, and was treated with a laparoscopic repair with a modified Sugarbaker technique.
Six months after surgery, follow-up with the patient has shown no evidence of recurrence.
Key Words: Laparoscopy, Abdominal hernia, Surgical stomas, Surgical procedures, Minimally invasive
A parastomal hernia is a common complication in pa-
tients with stoma formation . Many surgical approaches
for repair of parastomal hernias have been described. But,
the results have often been disappointing.
Recently, with further advancements in laparoscopic
surgery, laparoscopic repair of parastomal hernias have
been described with good results. Many investigations
have been reported that laparoscopic repair of parastomal
hernias with the proper technique can be safe, feasible and
reliable. Furthermore, these kinds of repairs offer all of the
well-known advantages of minimally invasive surgery
However, despite many advances in laparoscopic sur-
gery in Korea, there does not yet seem to have much expe-
rience in the treatment of laparoscopic parastomal hernia.
In Korea, as far as we know, laparoscopic repair of a para-
stomal hernia with a modified Sugarbaker technique has
not yet been performed. Herein, we present a case report
of a patient suffering from a large parastomal and inci-
sional hernias who underwent laparoscopic parastomal
hernia repair with a modified Sugarbaker technique.
Duck Hyoun Jeong, et al.
Fig. 1. Large parastomal (A) and incisional hernias (B). The patient visited the emergency room with severe abdominal pain and vomiting.
Fig. 2. Abdominopelvic computed tomography showed a large parastomal hernia (A) with concomitant incisional hernias (B) and a loss of
fascia around the ostomy site with herniation of small bowel and greater omentum.
A 79-year-old woman, who had undergone an abdomi-
noperineal resection for an adenocarcinoma (pT3N0M0,
stage II) of the rectum 9 years ago, visited the emergency
room with severe abdominal pain and vomiting. She was
later diagnosed with a large parastomal and incisional
hernias (Fig. 1). She first noticed the parastomal hernia
seven years ago. In the past, she sometimes had difficulty
with fitting stoma appliances and complained of dis-
comfort due to the severe parastomal hernia. But, she was
On preoperative abdominopelvic computed tomog-
raphy (CT), a large parastomal hernia with concomitant
incisional hernia was observed with a loss of fascia around
her ostomy. Herniation of small bowel and greater omen-
tum was observed (Fig. 2).
Although the patient experienced some improvement
of symptoms with conservative management early in her
hospital stay, the authors determined that a laparoscopic
surgery for correction of the parastomal hernia would be
necessary for long-term management.
Intravenous prophylactic antibiotics were given during
induction of anesthesia, and the patient was operated un-
der general anesthesia with endotracheal intubation. The
patient was positioned supine with both arms alongside
her body. The stoma was covered with a gauze and the sto-
ma site was covered with a clean Ioban drape (3M, St. Paul,
Positioning of the surgeons, trocars and video equip-
ment is shown is given in Fig. 3. Both surgeon and assis-
tant stood on the side of the patient opposite to the stoma
site. The first 12 mm balloon trocar intended for the cam-
era was created with an open Hasson technique at the side
Laparoscopic repair of parastomal hernia
Fig. 3. Positioning of trocars, operator and equipment for the
laparoscopic repair of a parastomal hernia of a left sided colostomy
with supraumbilical incisional hernia.
Fig. 4. Laparoscopic views of operation procedures. (A) The incisional hernia sac. (B) Incisional hernia was closed using an Endo Closure
device. (C) Composite mesh was applied with Sugarbaker technique. (D) The margin of the mesh was fixed with a mechanical fixation device
(autosuture endoscopic tacker).
opposite to the stoma, and a pneumoperitoneum was cre-
ated with 12 mmHg of intraoperative abdominal pressure.
Afterwards, a 30o angled, 10 mm scope was introduced.
Next, a second 5 mm trocar was inserted subcostally.
Finally, a third 12 mm trocar was placed just above the su-
perior iliac crest (Fig. 3).
After complete lysis of adhesion with sharp dissection
of the anterior abdominal wall, we measured the hernia
defect and inspected concomitant incisional hernia (Fig.
4A). The parastomal hernia sac size was measured to be 7
cm × 5 cm and the concomitant incisional hernia sac size
was 6 cm × 5 cm. The extent of the parastomal and inci-
sional hernia defect were marked on the abdomen. A size
of mesh was fit according to these marking such that it
would be large enough to cover all hernia defects by at
least 5 cm in all directions.
Before mesh application, the midline incisional hernia
was closed with 1-0 Vicryl sutures using the Endo close
Trocar Site Closure Device (Covidien, Mansfield, MA,
USA) through separate small skin incisions (Fig. 4B). We
used a 25 cm × 20 cm sized PARIETENE Composite mesh
(Covidien) which was used as the original without cutting.
Orientation marks were made on the mesh and on the
abdominal wall to allow for proper intraperitoneal ori-
entation of the mesh. The first sutures were placed at the
orientation marks before the mesh was inserted into the
abdomen. The mesh was subsequently oriented using the
orientation marks and the sutures were extracted through
separate small skin incisions at the orientation marks with
an Endo close Trocar Site Closure Device. The sutures
were tied down to the anterior abdominal fascia, thus cre-
ating transabdominal fixation sutures.
We placed a transfascial fixation suture laterally in the
mesh just above and just underneath the lateralized bowel
(Fig. 4C) and more sutures were placed all around the mesh
at its margins. Further fixation was performed with a me-
chanical fixation device-Autosuture endoscopic tacker
Duck Hyoun Jeong, et al.
Fig. 5. Appearance of the abdomen after surgery.
Fig. 6. Outpatient clinic after sur-
(Endo Universal 65o devices, 4.8 mm stapler)-at the margin
of the mesh with an interval of about 1 to 2 cm (Fig. 4D).
Total operating time was 340 minutes and there were no
complications during the procedure (Fig. 5). At post-
operative day (POD) #1, the patient started tolerating sips
of water, and at POD #3, a soft diet was started. Following
a brief ileus, the patient was discharged one week after
surgery with no other complications. Now, 6 months after
surgery, the patient has shown no evidence of recurrence
Parastomal hernias continue to be a common complica-
tion after stomal surgery . Their rate of incidence varies
between 4% and 48%. Although most asymptomatic her-
nias are well tolerated and can be managed conservatively,
approximately 30% of hernias require surgical inter-
vention for symptoms that include bowel strangulation,
obstruction, bleeding, parastomal pain, poorly fitting ap-
pliances, and leakage .
Many different surgical approaches for repair of para-
stomal hernias have been described. The three most com-
mon surgical approaches are primary fascial repair, stoma
relocation, and repair with mesh. Direct primary fascia re-
pair at hernia site had reported recurrence rates of 38% to
100% , Additionally, stoma relocation does not remove
the risk of parastomal hernia developing at the new stoma
site and incisional hernia can still develop at the previous
stoma closure site. A repair with mesh has shown im-
proved results over stoma relocation and primary fascial
Recently, with increasing research and advancement in
laparoscopic surgery, a laparoscopic method for repair of
parastomal hernias with mesh was described, with good
results on short-term follow-up [2,3,5,6]. Laparoscopic
parastomal hernia repair can be divided into two main
groups: Keyhole techniques and Sugarbaker techniques.
Keyhole techniques have been described in several differ-
ent ways [3,5]. But, they all have an intraperitoneal mesh
Laparoscopic repair of parastomal hernia
with a central hole to allow the colon or ileum to pass
through the mesh to go to the stoma site. Sugarbaker tech-
niques have no hole in the mesh, but rather the bowel go-
ing to the stoma is lateralized and covered by the mesh
In 1980, Sugarbaker  first described an open techni-
que for repair of parastomal hernia using an intra-
peritoneally placed polypropylene mesh . In 1998, it
was reported the first case on laparoscopic parastomal
hernia repair with a "Sugarbaker technique" and in 1999, it
was reported a case of a laparoscopic repair of a para-
stomal hernia with "Keyhole techniques" by Bickel et al.
Modified Sugarbaker technique was first described by
Stelzner et al.  in 2004. By laparotomy, an intra-
peritoneal expanded polytetrafluoroethylene mesh was
placed with overlap the edges of the fascia by of at least 5
cm in all directions. In 20 patients, with a mean follow up
of 3.5 years, they saw three asymptomatic recurrences.
In 2007, Muysoms  reported a “Laparoscopic modi-
fied Sugarbaker technique for parastomal hernia” in five
patients with good early results, no early recurrences and
good functional outcome.
In many investigations, it has been reported that laparo-
scopic repair of parastomal hernia is a safe, feasible and re-
liable technique offering the well-known advantages of
minimally invasive surgery. However, despite many ad-
vances in laparoscopic surgery in Korea, there does not yet
seem to have much experience in the treatment of laparo-
scopic parastomal hernia. It was no until 2005 that Lee et
al.  reported laparoscopic repair of parastomal hernia
using Keyhole-technique for the first time in Korea.
However, some reports using keyhole techniques have
shown disappointing results with many recurrences [2,8].
For example, Safadi  reported a recurrence rate of 56%
(5/9 patients) within 6 months of the operation. Muysoms
 also reported a disappointing experience and high re-
currence rates with the “Keyhole technique”.
Recently, reports have shown that the Sugarbaker tech-
nique has lower recurrence rates compared to the Keyhole
technique [6,8]. Muysoms  reported that laparoscopic
parastomal hernia repair with “Keyhole techniques” had
an unacceptably high recurrence rate. therefore, he
changed to a “laparoscopic Sugarbaker technique” with
more promising early results. Asif et al.  reported that
the modified Sugarbaker technique may offer patients a
significant decrease in the risk of recurrence with no sig-
nificant increase in postoperative complications com-
pared to other parastomal hernia repair techniques.
For incisional hernia, already laparoscopic treatment
with the mesh is considered gold standard of treatment.
For parastomal hernias, it seems that the global trend is
shifting towards using a Sugarbaker technique rather than
In conclusion, we found that laparoscopic repair of a
parastomal hernia with a modified Sugarbaker technique
can be a safe and technically feasible. It is a mechanically
logical technique combining the advantages of minimally
invasive surgery with a favorable intra-abdominal pres-
sure gradient. The viability of this approach, however, de-
pends on longer-term follow-up reports with greater stat-
istical power, and standardization of technical details.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
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