VM30 - Robotic Retromuscular Repair of Type-II Parastomal Hernia with Totally Extraperitoneal Technique

Purpose/Background: A parastomal hernia following radical cystectomy and ileal conduit urinary diversion is a condition that is often underestimated and inadequately treated, despite its substantial impact on an individual's quality of life. It is usually accompanied by an incisional hernia related to the initial surgery. Numerous surgical approaches have been documented for its management, including onlay, sublay, and inlay methods. In the sublay (retromuscular) approach, a mesh is positioned between the rectus muscle and the posterior rectus sheath, thereby preventing direct contact of the mesh with the intraperitoneal space, which can lead to issues such as adhesion, erosion, and fistula formation.

Methods/Interventions: A 76-year-old male with a history of radical cystectomy and ileal conduit/urinary diversion due to bladder cancer in 2021, was presented to our clinic with multiple incisional and parastomal hernias. A plan was made for hernia repair using a robotic extraperitoneal retromuscular and keyhole technique.

Results/Outcomes: The da Vinci Xi robotic system was used. For the operation, three 8 mm robotic trocars were placed in the lateral of left rectus sheath under general anesthesia in the supine position. Dissection was begun and continued in the preperitoneal space until the right transversus muscle was located. Then, the rectus sheath was completely dissected, and a bottom-to-top release procedure was performed. The area around the stoma was dissected, and the parastomal hernia was freed from the surrounding tissues. Before placing the mesh, defects both in the parastomal hernia and also the median fascia were repaired with V-loc sutures. Peritoneal openings were similarly closed with V-loc sutures. First, a polypropylene mesh was placed under the fascia around the stoma and secured with 3-0 Vicryl sutures. Subsequently, a mesh was placed over the peritoneum for the incisional hernias in the midline and was adjusted to the appropriate size around the stoma to avoid narrowing it. The patient was discharged without any issues after the surgery.

Conclusion/Discussion: The robotic extraperitoneal retromuscular technique is a safe and feasible approach for parastomal hernia repair. It helps prevent intraperitoneal adhesions and allows for the optimal placement of the mesh in the retromuscular space.