Record btk-20250108_204554-Meeting Recording

All right. Hello. Once again, to our behind the knife listeners we're very excited to be back with you for another episode coming to you from the Leahy colorectal surgery team. So for this episode, we're going to be grappling with the challenge of how do you manage, potentially even how do you prevent peristomal hernias?

And so what do you do when you have them? How do you prevent them? So you'll hear a bunch of tips and tricks from us. So I'm joined once again by Dr. Peter West Marcello and Dr. Tess Hanna Allett. Say hi, everybody. Hey guys it's wintertime and so I always, you know, wintertime is ski season and I gotta say it's not been very good in the northeast.

Very little snow, bunch of rain, but I'm getting ready for Midwest Colorectal Society meeting so a shout out to them. It's in Park City in March 6th to March 8th if anybody's free. Dr. Abelson will be joining me. Tess, how are things for you? Things are

good. My voice could be better, but I swear I'm feeling good.

I'm going to be actually in Park City a few weeks later for my husband's ENT conference. So nice. Just warm up, warm up the slopes for me. All right, you're bringing Sam's now four. Is that right? Yeah, we'll see if we can get him to go down the mountain with us. Nice. John? Yeah, we're doing we're doing ski lessons for the kiddo.

So, you know, it's been fun. Had him on the skis this weekend. So, you know, we're getting there. We're getting there. All right. So before we get into our topic we do have a special guest. So I'll introduce Dr. Paul Sturrock from UMass Memorial. So Dr. Sturrock did his surgical training at UMass Memorial.

Colorectal fellowship was at Brown. He's the director of robotics and I've heard an endoluminal stent whisperer. He is a surgeon who's always looking to prevent peristalmal hernias, and we're certainly looking forward to hearing his perspective on the use of extraperitoneal colostomy creation.

So welcome.

Thank you. It's great to be here. I'm excited to talk a little bit about peristalmal hernias and you know, I've done a lot of work trying to prevent them, minimize them and their comorbidities. So, happy to talk with you guys about it tonight. And thanks Paul for joining me. And now I'm not.

Outnumbered with these Leahy people. It's a two on two for tonight, UMass versus Leahy. Let's test train here. I'd say it's two and a half against one and a half, but I'll make it two to two for tonight. Go ahead, John. Get us going. Yeah, enough, enough infighting. So let's jump into the topic for today. So, As you know, we like to start with a case.

Okay, so this is a 64 year old female. She's diagnosed with a distal rectal cancer. This is she's not a candidate for a sphincter preservation. She completes her total neoadjuvant therapy, has residual disease, and perineal resection. So, Tess, what are your, some of your considerations pre op when you know

you're going to be creating a permanent colostomy?

Yeah, so, anytime I'm making a stoma, especially a permanent one, we want to have them meet with one of the wound care stoma nurses make sure that the patient gets education and that they have stoma marking. Pre op stoma marking has been shown to. You know, decrease patient complications, improve their quality of life, being able to manage this post operatively and being independent.

I'll put a plug in now for the residents and fellows while there's still time left in the in this year to spend some time with the stoma nurses during your training so that, you know, in the middle of the night, emergency cases, you're, you know, able to do this on your own and get some more information about this.

If you look at our PowerPoint, if you're following along on YouTube, there's some pictures kind of diagramming how to do stoma marking, but want to make sure we avoid bony prominences, skin folds, creases, and have our stomas within the rectus

sheath. I also talk to patients about what living with a stoma is like during my pre op visit.

Discuss the differences between ileostomy, colostomy, depending on what they're going to have. The other thing is if you're planning to do a flap, making sure you're talking to your plastics colleagues about how this might impact the flap, um, stoma and probably would avoid like a rectus flap. I do always discuss the risk of peristomal hernia and tell them it's sometimes inevitable.

And we'll talk a little bit about the use of extraperitoneal colostomy. I think for your permanent stomas, this is a really great option. Previous randomized trial looking at using mesh prophylactically was published in Annals of Surgery in 2017, did not show any benefit in decreasing the rate of colostomy.

Parasomal hernia, so I don't routinely use mesh prophylactically. Yeah, it's a good, it's a good point, Tess. Peter, Paul, are you guys using mesh prophylactically in these situations?

So, I'll just chime in to say that, you know, I've been trying my whole career to prevent stomal hernias and you can talk about the skill or technique, but it's really abdominal pressure.

So, I came through the era where mesh was being utilized in a sublay. The studies that showed benefit in randomized fashion came from Sweden. We're using Polypropylene, but everybody got nervous about polypropylene and the risk for infection. So then there were a whole host of biologics that were utilized, both in an above lay or underlay, or using a circular stapler to try to, with mesh or without mesh.

The only one that showed benefit was polypropylene. But I always got tired of it. And what was interesting for me was that in my journey I started learning about an extraperitoneal approach when I was visiting France at IRCAD we were doing laparoscopic surgery and I watched Joel Law do a Gallagher approach, which we'll talk about in a minute.

Then I went to the Midwest colorectal meeting and I saw Al

Thorson, a former president of our society. Do the same thing. And I was like, this, maybe this makes some sense. So let's move to the next slide. For those joining us on with a video, please look, I'll describe otherwise. So John Gallagher was a very famous colorectal surgeon at the Leeds Infirmary in England in 1958.

He described the extraperitoneal colostomy. And basically the concept is you make a hole in the skin, you open the anterior rictus sheath vertically, you come under the muscle, and then you dissect out laterally to the sidewall. And then at the junction of the anterior you incise that junction point.

And then you stay in the extraperitoneal plane, and you go out probably to sort of midclavicular, midaxillary line, and then open the peritoneum. And then the colon is brought. Through this tunnel and it's a natural tunnel and I'd say a natural sugar maker. Let's go to the next slide That shows the skin opening This is showing making the tunnel which

goes again at that plane between the anterior posterior sheath gets open you stay extra perineal till you get laterally and then swing the colon through you have to sort of snake it through and we'll talk later about some tips and tricks.

This approach makes sense because then the anterior and posterior openings are offset so that you can't really create the hernia through the posterior sheath in the same area where the anterior opening is. And so, next slide. We go through. So if you do a CAT scan afterwards, it looks really kind of funky because the colon is coming around and you'd worry, is the colon going to obstruct coming through the tunnel or is the tunnel going to block the stool from coming through, but it works.

It's natural. It works. It doesn't require any mesh. Treatment, and let's go to the next slide and it just so happens I'm in the office today and I made a Gallagher extraperineal colostomy over a year ago, and this patient gave me permission to use his picture. He's all excited that he's going to go on Behind the Knife.

He

doesn't even know quite what it is, but I know he's excited. So Bob was really excited, and he's a year later, he's obese. and no hernia. And I'm just very happy. Paul, what, give us your thoughts on this. How did you get to the journey of thinking about this and what's your, your road to it? So it's interesting.

When I first started thinking about it, when we had a visiting professorship with Dr. Stan Goldberg from Minnesota. And one of the cases that we presented to him or our residents presented to him had to do with the efforts that we were making with the EEA stapler at the time to try to create a defined defect in the abdominal wall that wouldn't expand, wouldn't allow for creation of a hernia.

And unfortunately, That study never really panned out. The, the fascial defect would open up just as if you had created it with electrocautery, so there was really no difference in the hernia rate. So we, but we got to talking about that afterwards and he had mentioned this whole idea of the Gallagher approach

and.

We're talking back and forth about how it seemed to really have fallen by the wayside because of the increase of minimally invasive surgery for rectal cancer operations and proctectomy. And it was just a little bit more of a technical Toward a force in a laparoscopic field as opposed to an open approach, whereas he was describing it, you could just take your finger and, you know, create this tunnel in the perineum, just going up from where you incised the sigmoid laterally.

And it was, you know, like a five minute maneuver to be able to get that peritoneal tunnel ready. So I started thinking about whether there were any ways for us to be able to do that in a laparoscopic approach. In, in, in, In doing so with our minimally invasive surgeons doing a lot of obesity surgery they, for a time we're using a a gastric band procedure and they would have a special device to pass the gastric band around.

The GE junction and this lap

band passer, there's a 10 millimeter instrument that you could turn at the end so it would create kind of a bent finger is what it really looks like that has a 90 degree turn to it. So I use that the first time that I tried this technique laparoscopically to be able to raise that peritoneal flap from the lateral edge where the sigmoid was in, the sigmoid peritoneum was incised going back towards the abdominal wall.

And I found that I could get about two thirds of the way that I wanted to get to where the, that lateral tunnel was going to come from the anterior abdominal wall. So then doing that with, you know, the, the external approach as you described of just going a little bit lateral to the rectus and incising that transversalis to be able to get lateral.

I was able to be able to meet that tunnel fairly easily. And then it became much less onerous to be able to bring the Bring the colon up through that tunnel to create the extra peritoneal colostomy. Also, you know, having done more robotic surgery in

the last several years using the articulated instruments of the robot, you can create that tunnel that way as well.

So that's another way with the minimally invasive field that you can use the articulation of the instruments to work your way back to the underside of the abdominal wall. So that made it really much more feasible for us to do without making it so technically complex that you would want to avoid it at the end of a long proctectomy.

It's a great point about the robotic approach. I have done this several times with Peter's guidance laparoscopically and hand assist. I have tried a few times robotically, and I just haven't been able to quite figure out the port placement and the articulation. for your attention. You know, I know a lot of times we'll try to place one of the ports through the colostomy site in order to minimize the morbidity of fascial incisions.

But that actually would be against what you would be trying to do for extra peritoneal colostomy creation. So I guess your thoughts about port placement and how you sort of have worked that and same concept for lap also. So for for the

robotic approach, you know, I typically have kind of a diagonal line from the right lower quadrant to the left upper quadrant.

So the right lower quadrant port is the one that I'm using to be able to elevate that peritoneal flap. For me, that's usually a 12 millimeter port so that I can staple off the colon proximally. So if I'm having trouble. Then I can just convert to a laparoscopic approach and use that band passer to be able to finish making that tunnel if the angles for the laparoscopic or the robotic instruments are not allowing me to get back on the abdominal wall, you know, back closer to the midline as far as I'd want to get.

And laparoscopically, same thing, you know, it's the right lower quadrant port that I typically use and make that either 12 millimeter port, you know, certainly a 12 if we're going to use a stapler and then that bandpasser instrument can be used from there to go across the abdomen and work your way back towards the midline.

Hey, Tess, what are your thoughts about this? Yeah, I mean, I love, I haven't really had as much experience yet early in practice, but it's been really, you know, something during fellowship that I wanted to bring with me, and so it's been great to have another partner who's doing this to be able to kind of learn additional tips and tricks.

Are there, you know, some of the things that we've kind of touched on, and I. And one of the things that I worry about, too, is, you know, any kind of pitfalls that you guys have seen in doing, you know, a number of these. I know our group at UMass, we recently presented on our series and, you know, at one year didn't have any hernias in a series of patients which is awesome and really no increased complications as well.

I think, as you mentioned, Marcello, the concern is, you know, are they going to get obstructed? I feel like anecdotally in fellowship, maybe they were a little slower return of all

function, but again, we didn't find any like statistically significant differences. Anyone kind of want to chime in on like pitfalls or things that you've kind of learned along the way after doing a more more of these.

Yeah, I'll just say that I think the thing that's helped me the most is actually using the EEA scisors. So when I make the opening outside the body, open the skin, open the fascia and go under the muscle once I open up that lateral junction between the anterior posterior sheath, the EEA scisors, like either they're small or medium, and you wiggle it and that really helps to create the tunnel out laterally.

And then laterally I actually just used two instruments from the right side laparoscopically to pull the peritoneum back. And by pulling the peritoneum back and coming from the outside with the EA sizers, you can meet where you need to. I did have one case where I cut into the peritoneal cavity at that junction.

It was too soon. So I just

recreated the tunnel and I closed that part of the defect. I think what also was really interesting is we don't really know how far laterally do they have to offset. You know, Gallagher describes it going way out to the mid axillary line. Maybe you don't need more than five or six centimeters.

And so I think We need studies to figure out how to make this optimal, and I've had cases of an ileostomy which is hard to make that long tail. You really need, left colon worked great, descending colon is great because you can base it upon an ascending branch of the left colic, have a nice long snake of a colon to bring through the tunnel, but on the ileostomy there are arborization of the vessels.

So I've actually had a case where I've gone the other way. I made the opening in the posterior sheath more medial. Laparoscopically, and then I've gone under and then up. So I think the key is to offset the interim poster openings. Does it matter which way you go or how you do it? I don't think we know.

And I think that's what's exciting is that We've got opportunities now to take the concept of

offsetting our incisions to make it better. Yeah, and I would just add that, you know, from a pitfall standpoint, you know, the risk of obstruction, I think Peter, as you described with using the sizer, or if you're able to get more dissection from the intra abdominal field, making that tunnel, You know, as wide as you can.

It really takes any of the pressure off and minimizes the chance that it's going to scar or stricture down to the point that you're going to get any type of functional obstruction. You know, in the series that we've published, we had one you know, stricture or retraction of the colostomy from the extra peritoneal approach.

Which, you know, caused obstruction almost at the skin level because the stoma retracted. But surprisingly enough, I was able to locally revise that and pull more of the colon through the tunnel. And it turns out that I just hadn't brought enough colon through the tunnel to be able to get it to sit up nicely as a colostomy.

It wasn't anything about the tunnel that was causing it to be constricted or

narrowed. It was just my failure to mobilize enough colon to be able to get through. a good stoma to sit up above the skin level. That's a good trick. You gotta mobilize a lot. Go, go, go. John get us moving forward. Yeah, sure.

So, yeah, let's get back to the case in touch about a couple other aspects of parasomal hernias. So, So this let's say this patient that we presented earlier undergoes and colostomy creations two years prior. And now she's in the emergency department. She has acute onset of abdominal pain, nausea, vomiting, and now CT scan demonstrates a small bowel obstruction with a transition peristomal hernia.

So, test, why don't you talk us through a little bit how you're thinking about these clinical presentations? Yeah, absolutely. So I would go, you know, see the patient, want to know their vital signs look at the prior incisions, examine the hernia. If the patient's hemodynamically stable versus unstable and then looking at the CAT

scan for any signs of boluschemia perforation if everything, you know, they're hemodynamically stable, no signs of perforation would attempt to see if the hernia is reducible at the bedside to try to relieve the obstruction and avoid.

And I think it's really important to highlight the need for emergency operation. I do think looking at the CAT scan can be helpful to know when you're pushing and being able to reduce these successfully, especially in patients with. a larger body habitus. This can be challenging, so really correlating with the CATS CAN in terms of trying to reduce these successfully.

Obviously if there's signs of perforation, boluschemia or strangulation, then I'd bring them to the operating room. And ideally, if I don't need to go to the OR try to wait out, not operate emergently and get them through the obstruction if we can non operatively and then discuss elective repair in the outpatient setting.

That way I can get a, a better sense of you know,

is a patient symptomatic? Are they having pain? Are they having issues with the appliance leaking or difficulty maintaining a seal, skin irritation? And then if they're having complications such as prolapse, obstruction you know, this would lead me more to discussing and recommending an elective repair.

And then if I am going to do this, making sure to kind of optimize them as much as I can in terms of weight loss Smoking cessation, diabetes control. If possible. Yeah I think that's great. And I definitely agree. I mean, I think you know, the emergent urgent repairs you definitely I think it's really just getting the patient through the episode and not necessarily thinking that you're gonna prevent a hernia from ever coming back.

So I guess maybe, Tess, do you wanna, do you wanna talk to us then about some of the repair options? Yeah, on either elected basis with an urgent basis. Yeah. So kind of broad strokes. We have primary repair, which usually is

not done in the elective setting, given extremely high recurrence rates up to 80%.

Similarly, stoma reciting. Is an option, but usually not recommended, given they probably are laparotomy, high risk of recurrence and again, maybe better for the acute setting, depending on intraoperative findings. But the other options you have are onlay mesh repair sublay. Extra peritoneal, intraperitoneal mesh repairs retrorectus you know, abdominal wall reconstruction keyhole technique for mesh placement, where there's a slit basically cut and kind of wrapping around the stoma.

One that most people favor is a sugar baker approach for an elective repair where basically you're almost creating with mesh a hammock where you lateralize the bowel and kind of wrap the mesh around it in order to prevent that hernia from coming back. And so I think all of these kind of have pros and cons in a place depending on the scenario.

But definitely kind of more

for your elective hernia would, would favor a sugar, sugar baker approach. Yeah, I, I would tend to agree that I would say my, my go to is the sugar baker approach. Peter, Paul, thoughts about repair options. So, I'll just say, in the elective setting I will work very hard laparoscopically to divide adhesions to allow for a laparoscopic sugar maker.

Because I think the view is so good, robotically or laparoscopically, that it's worth the extra time of adhesiolysis to spend the time. Because doing an open sugar baker is really, you know, hard or complicated and I think the results are really good. And again, it's just a artificial golliger. So you're just lateralizing, offsetting.

And so, the prevention is the important part, but if I, I, I, my, my point is I will do whatever it takes to get Latin, stay laparoscopic and try to avoid an open operation. That's what I'll I'll say is my pearl. Paul, I mean, I would agree my go to would be the minimally invasive sugar

baker, whether it's lap or robotic same points as you described that the view is so much better.

The ability to place the mesh is so much clearer rather than kind of looking underneath the hood, trying to see the abdominal wall from an open approach to be able to get the mesh fixated the way that I want to. So I'm not a huge fan of the keyhole mesh procedure. Especially in talking with some of our MIS folks, they feel that that slit in the mesh just kind of weakens it too much, and you're set up for a recurrent hernia at that site.

So, I tend to avoid that approach if possible. All right, so let's say we're back to that case, and Tess, you're not able to reduce that hernia, and they still have an obstruction. So, so how are you going to repair that? How are you going to approach that surgically? Yeah so you can kind of think about this in two ways.

One is laboratory or potentially locally at the site of the stoma. So what I would do is with the stoma appliance in place at the

beginning of the operation, mark my incisions to try to make it so it's outside of the stoma appliance. I would then, you know, make my incision over the hernia. Again, this is where CT is helpful to correlate and make sure you're planning your incisions well.

If I can cut down and get into the hernia sac and the bowel is viable, you might be able to I'm going to use the word reduce it and repair the hernia. If it's ischemic, then I'd probably opt for a laparotomy and resection to be able to adequately assess this and do it in a safe fashion.

You know, again Once you've kind of dealt with the bowel, how do you deal with the peristal myhernia? I think, you know, doing it with or without mesh depends on the degree of contamination would likely favor trying to use a mesh if there's no significant contamination or again, if there's contamination you know, maybe in a small defect, potentially a primary repair understanding that there might be a high rate of recurrence and probably need to come back at

some point in the, in the future.

Yeah, Paul, thoughts about how you would manage that situation. Yeah, so I, I would favor more in that acute setting, just a primary repair to decrease the size of the stoma opening at the fascial level. One of the things we have now had available to us at UMass for the last year or so a product called Duramesh sutures.

It's kind of a woven polypropylene suture. That has a little bit more surface area to it than a standard simple stitch. So it grabs a little bit more of the fascia and disperses some of the tension across your stitch a little bit better. So I've used those put two or three interrupted sutures there just to close the fascial defect.

With an understanding that if it's going to recur and they need an elective definitive repair that you're really just trying to get them through this acute obstructive episode so that they don't reincarcerate post op. I think that's good, good advice. My key is As

Tess said, you got to mark the skin with the wafer on before you prep and drape, number one, so that you have that mark outside.

Number two, put a Keith needle across the stoma so that you don't let it retract inside, especially if it's an ileostomy that there's a obstructing parastomal hernia that's an ileostomy. Number three is, I like Dermabond on the skin. Rather than, you know, close it with a subcuticular and then Dermabond it so you can get the wafer back on.

That helps. The last thing I want to talk, just, just talk about a little bit on the other side is if you're closing an ileostomy or colostomy and you have a hernia at the site of the closure, you know, what do you do there? It's always under tension. So, we've come up with a concept we can go to the next slide and I'll just shout it out.

Why not just do a little bit of an anterior component separation? When you're closing the ostomy go out three inches laterally to the external oblique and size the External oblique fascia and now the lateral edge of the anterior rectus teeth will

come back to the medial side without tension Component separation has been shown to reduce hernias in the midline.

So why not do it at a stoneless site? Next slide. So by doing that you release It's the lot, the tension laterally and so it comes back immediately and allows them for the primary repair of the, of the stoma site with the relaxation and component separation. So that's my tip and tricks. Are you, Marcelo, are you doing that with every closure or just big?

Only if it's tight. Like if it's no tension, you don't need it. But if you've got a big hernia in the fascia. When I close it, do a component separation, go out laterally to the same incision, and you're not adding much time, effort, and you're not putting in mesh. Yeah. Yeah, so Tess, we are, I think one of the updates since your fellowship year is we are prospectively collecting size of that fascial defect so we can better be able to demonstrate the success of this based on the size

of the hernia defect.

Correct. More to come. More to come. Alright, well that was the end of the session. Parasomal hernias and more. Alright, so Tess, you're going to take us home. You know the deal. Alright, if the patient is having an elective repair, optimize them if you can. Know a few ways to tackle the problem and then be familiar with the mesh at your institution.

As Starek said, I just recently learned about this DuraMesh suture and so you can always kind of find some new things depending on what new products are coming in. Nice. Marcel's must knows if when you're making a permanent stoma, I think you got to use an extra perineal approach if you can. And we need to work together to figure out exactly how to do this both her ileostomy and colostomy and what are the minimum requirements, but I really believe it can prevent hernias long term.

If you're going to, if you have a hernia, you got to fix spend the time for a lap scrub or sugar baker. And if you're closing a

stoma that has a hernia at the site, consider a anterior component separation to prevent future hernia at the stoma site. Awesome. All right. Dr. Sturek, Sturek's sage advice.

So the biggest things I would say in having dealt with this for many years is that working to prevent a peristomal hernia at the initial operation is much better than treating a peristomal hernia afterwards. And as Dr. Marcel mentioned you know, an ounce of prevention is better, is worth a pound of cure.

Thank you. The, the other thing that I would remind people is that if you're worried that you're not going to be able to do the parrot, the extra parrot neocolostomy, you can always try to make the tunnel. And if you really don't feel like it's working, then you can just make your posterior incision behind your anterior incision and bring the stoma straight up.

And we've certainly had that happen before on a short mesentery or something, but it's worth the effort because oftentimes you're surprised,

even if you don't think it's going to work. There's plenty of length on the colon and the mesentery to make it work, and then the patient's going to be set up better for the long term.

Yeah, just Abelson's approach. I would say it's really just building off of that. And this is more, I guess, being more explicit and talking from personal experience that. You know, oftentimes these can be very, very challenging cases, long cases. And so you're like, okay, thank God. All I have to do is just create the colostomy.

And then you're like, oh my gosh, now I need to mobilize more. And I got to create a tunnel and all these things. And so, and I've definitely found myself on a few occasions just saying, okay, I need to like actually pause for a second. And sometimes that means you're like, Step out of the room, you're taking a little break, okay?

And you're just saying, what's going to be the best thing for this patient long term? And so then you're like, okay, I have to put in the work to make a good stomach because this is going to be permanent. And I think what you've heard from all of us talking here is just talk with your peers, innovate, talk to your MIS colleagues, talk to your your, your, your friendly colorectal surgeon you know, and see what other people are doing, see what's working, what they're trying innovate and let's see

what we can do to Make this problem go away.

All right. All right. So with that, we're going to wrap up our session. So again, if you like diving into the weeds consider joining us Sunday evenings for our colorectal surgery, virtual education series. And then if you enjoyed this session do you take a minute or 2 out of your hectic day to leave us a review?

So, as behind the knife says until the next time dominate today.