Episode 4- CCFparastomalhernia

Hello and welcome to another episode of Behind the Knife with the hernia team at Cleveland Clinic. I'm Sarah Maskell, here with the rest of my team. I'm Ryan Ellis, general surgery resident at the Cleveland Clinic. Luke Betha, assistant professor of surgery. Ajita Prabhu, professor of surgery. Today we're going to talk about a complex topic in hernia surgery, peristomal hernias.

So to start off, we want to go through some of the preoperative considerations. Considering the high prevalence of peristomal hernias, what are the signs and or symptoms that prompt you to offer patients peristomal hernia repair? That's a great question. We see patients in the office all the time that have newly diagnosed peristomal hernias.

I would say, first of all, it's important to establish why you're operating on these patients to begin with. Unlike other types of hernias, I would say I tend to stray away from Operating on patients if they don't have symptoms for this type of hernia because they really do have a high recurrence rate post operatively if you follow them out.

So for me at least, when I see

them in the office, The first things that I want to know are if they have pain around the stoma, if they are having difficulty pouching their stoma, so if they're having leakage related to the contour. So, one of the things I want to know is if they're having leakage around or underneath their pouch and having difficulty pouching as a result due to the contour of their abdominal wall where the hernia is sticking out underneath the skin.

And then finally, if they're having obstructive symptoms, I think any of those things, if they're having difficulty pouching, if they're having pain, or if they're having obstructive symptoms, those for me are good indications to go to the operating room. Yeah, I think that's a great summary and great introduction to it.

I also would add to the fact that peristomal hernias, whether it's a GI diversion, like an ileostomy or a colostomy, or it's a urinary diversion, like an ileoconduit that, those cases are extremely challenging for any surgeon to tackle and to do even for us that do them

frequently. And so I think having a sound indication that you're going into the surgery for, well established with the patient, and defining those expectations up front, could just set you up for success on the, on the back end and the post operative course, so that everyone's on kind of the same pages.

And I agree with Dr. Rabu that, you know, You should really have a strong indication to fix these because they are challenging hernias to fix that do have significant risk that can impact patient's quality of life for positive and negative. Since we're talking about how these tend to be more complex patients and they tend to have other issues, how often or when do you involve other teams like colorectal or urology?

I guess for me since you know, I haven't been at the clinic quite as long as Dr. Abu has, I think at first when I was here I involved often other specialties, probably more so than I do now. And part of that is just experience or lack of experience with them

initially. They do often cross over with multiple specialties, you know, like colorectal surgery, urology.

And so. I, if I were giving advice to a young surgeon or someone who's a resident or medical student, I would say definitely seek their opinion or advice early preoperatively. If you have any concerns at all that you might need to move the stoma, you're worried about injuring the stoma particularly for ileal conduits or urinary diversion they often involve some degree the ureter.

that has been re implanted into the bottom of whatever the conduit is. So you want to certainly make sure you're doing always what's safest for the patient. And if that means that you're not comfortable dissecting out a re implanted ureter, you need to have them, you know, help you do those things. And I would be aggressive with getting those people involved early.

I would say I'm still much the same way in that if I'm taking a patient to the OR that has a stoma I'll usually have a colorectal person, if

it's a GI stoma, or I'll have a urologist that I know they're at least operating on the same day and I'll schedule the operation such that if I need them, I can easily call them and have them come.

And I usually give them a heads up that I'm going to do the operation because it's usually one of their patients. And then I agree with you, Luke, that, you know, as you get towards where a ureteral anastomosis might be or that type of thing, if you're not. you know, strongly familiar with that type of anatomy, you may, or if you're not super comfortable with that kind of anatomy, you may have a low threshold to get a urologist involved.

And every once in a while, we'll have to take down a stoma and move it to an entirely different site. And if that is the case, I have a much lower threshold to get one of our colleagues involved from either colorectal or urology. And then the other case in which I have a low threshold to, to call them is even if I'm taking the stoma down and rematuring it in the same area, knowing that it's a permanent ostomy, I'll sometimes just ask them to come help with the maturing of the ostomy to make sure that it's something that's

going to work for the patient longterm because it really does affect their quality of life every day.

Yeah, one thing just while, while you were talking that came to my mind is preoperatively, I always, particularly for urinary diversion, I always look at the CAT scan to identify where the ureters are coursing because you were not there, I mean, you probably were not there when it was created. And so I found significant variability in how some surgeons divert or how the length of the conduit is, particularly for the ureters and the urinary diversion.

So I would say preoperatively, that's a great thing to really hone on it that I say that I always think about is if I have to mess a lot with the ureters or the ureters are inside the hernia, then I would have a very much less threshold to get somebody involved from another specialty just based off preoperative like imaging.

All right. So now that we have that intro I guess out of the way, let's get into some of the operative details about these operations. What is your typical operative approach to an isolated

peristomal hernia versus concomitant midline in peristomal hernia? That's a great question. So, if it's a small, isolated peristomal hernia, those to me are the ones that are really potentially great candidate for a laparoscopic or minimally invasive sugar baker approach, where we would place a barrier coated mesh into the abdomen, and lateralize the stoma using the mesh as essentially a sling for that stoma.

I will save that operation for an isolated, very small peristomal hernia type of defect. And that's about the only candidate that can be good for that. Sometimes people ask us if ileal conduits could be potential candidates for a minimally invasive sugar baker approach, and I do think they can be, as long as the conduit is long enough.

If it is a midline and peristomal concomitant type hernia, I'm more likely to approach that open. Although I have done a lab sugar baker on very, very small Swiss cheese

defects that are included in the midline along with that small isolated peristomal. But anything bigger than that midline Swiss cheese that's coinciding with a peristomal, I'm going to do that open.

And then I'll do a retromuscular approach and then we can get into those a little bit more in a minute here, but. Yeah, I would say if there's a large midline component or substantial midline component in addition to the parastomal, I'm going open for that. The only other thing I would think about that I always think about every time I see a parastomal hernia, which I feel is the best way to deal with it is, can it be reversed?

And that's the first thing that always crosses my mind is, does this person want the stoma forever? Which is fine to do that and do a big hernia repair and a mesh based repair off the stoma with it in place if they want it forever. My other thing I always think about is if they want it reversed, great, then do that first and then we can deal with the hernia down the road at a, in kind of a staged approach likely.

But that's the first thing I always think about every time I see anybody with a pair of stoma hernias. Okay, can it be reversed? Do you want to be reversed or not?

The first thing I think about is referring them to you. And then, but yeah, I agree with Dr. Regrue's approach. An MIS approach for small isolated bariostomal is a great, great way often.

Kind of related to this What's your preference for stoma disposition? Do you prefer to leave it in situ? Do you prefer to recite it? And kind of what's the decision making around that with the patient? That's a great question. I think it depends a little bit on what the stoma is. If it's an ileal conduit, I prefer to not rema mature it if possible and just leave it in its inside to position.

If it's a ileostomy or colostomy, the first thing I do is I ask the patient where do they want it? Because after we do these repairs, I don't want to have to go back to move it again or have the patient go back to move it in. So if they like it where it is, then great, we'll leave it there and work around it most of the time.

If the, there's a little caveat to that

in the fact that if the peristomal component, I feel super large, there's a large subcutaneous component to it. I feel it can be very difficult to leave those in situ and do a good hernia repair around that with digging all that, that bowel out of the huge peristomal subcutaneous component.

So sometimes I feel like it's easier to actually take that stoma down and if they want it in the same place, then I'll remature it at the same site. Or move it if the patient wants to be moved. The other thing I'll just add to that, the last thing I'll add to that is, what I've found and Dr.

Raghu, correct me if you have anything to say, but I would say oftentimes an ileostomy is best to be left on the right side of the abdomen and a colostomy is usually best to, at least an end or descending colostomy is the best on the left side. An ascending colostomy is probably better on the right side.

Okay. But those things do play a little bit of a role, I think, in patient outcomes, too. With, in regards particularly with lateralizing of the conduit with a sugar

baker style repair, if that's your plan. Yeah, I would agree with that for the most part. And the only other thing I would add to that is that when it comes to ileal conduits, there are some, things that are specific to the patients that have ileal conduit.

Specifically, that conduits empty with gravity. And so, if you talk to your urologist, they'll usually tell you that they prefer to have them come out lower on the abdomen so that they empty well with gravity. So, your options are fairly limited if you're trying to recite an ileal conduit. And so, they absolutely can be repositioned on the left side, which usually would involve a reconstruction and you know, a fair amount of technical expertise.

If you wanted to do that, it is possible to do that, but I definitely try very hard not to make that the case because that then burns another area it burns another bridge. for the future because I think by and large many of these hernias recur. And then I agree with you about

positioning of a colostomy, the right side for a right colostomy, the left side for a left colostomy.

There are times when a left colostomy can't be left in situ and then you got to do essentially a colectomy. To bring up a stoma on the right side. The ilium is probably a little bit more forgiving and can be brought to the left side, but for the most part, you're going to be doing a bowel resection if you're moving it from the right to the left.

So there are a couple of big names that are thrown around in peristalm repairs, and being the keyhole versus the sugar baker, and we wanted to have you guys kind of walk through each of those and treat them individually here. So can somebody just talk us through a retromuscular keyhole approach?

Sure.

So, a retromuscular keyhole approach is essentially what happens when we take down the posterior ectosheath on both sides. And depending on whether you take the stoma down and remature it or not, there are two different ways that you can do it technically. But the idea

is that there's a hole in the mesh that allows for the stoma to pass through it.

The stoma passes straight through the abdominal wall without being lateralized. And the hole is tailored to fit the stoma itself. And you have to be a little bit careful because the posterior erectus sheath, the mesh, and the muscle openings all have to align with the skin trephination too, so that the stoma does not become kinked.

So they can be a little bit tricky. And when it comes to making a keyhole repair I would say the My favorite approach is to take down the stoma and bring it up through a fresh hole in the mesh. And you can bring it back up in the exact same area, same trepanation in the skin and musculature.

But what that does is it avoids making a slit in the mesh. If you decide to leave the stoma in situ and not take it down, then where you lay your mesh out, laterally around the stoma. You got to cut a slit essentially laterally

into the mesh to allow the stoma to come through it. And then you have to decide what to do with the slit, which I think is kind of the weak side of that repair.

Historically, I had sewn that slip clothes with proline suture, although any more given the risk for erosion. Now I'll just lay the slits out laterally around the stoma itself. So for me, in general, if I'm going to do a keyhole retromuscular repair, I'll take the stoma down, make a fresh hole in the mesh, and bring it up straight through the mesh, the muscle the fascia, and the skin.

What about a sugar baker? Yeah a sugar baker is a little bit more complex in that, I can think of it a little bit, in that there's like four components, and you can control all four components. One is The first one starting from the bottom is the peritoneum, the second one is your mesh, the third one is the anterior fascia, and the fourth one is the skin.

And you have to control where each of those orifices and those holes that you make in those layers all

align in the right order. Otherwise have some pretty bad complications with sugar baked retromuscular sugar bakers. So, I would say you do your retromuscular dissection and in that regard you have, just like Dr.

Rubir had said earlier, is you have two options. You can leave the stoma inside or you can take it down. I tend to lean a little bit more, any more towards taking it down and either rematuring to the same side of the skin or moving the stoma but if you take it down you then will have to do your first layer, which is a lateral hole in the peritoneum.

And the art to this rather than the science is how far you go laterally. My, there isn't any hard number, but I would say as lateral as the bowel allow you to where you can still traverse, you know, through the posterior, through the mesh, and then up through the anterior to the skin and reach. So that's a little bit more of the art rather than the science of the hernia repair.

as lateral as you can get it. Then you would bring the stoma up through the peritoneal hole

and then you would lay in your mesh. And then I make a a cruciate incision in the mesh. I don't tend to make a circular incision in the mesh. I just make a cruciate incision in the mesh. I would then bring the stoma through the cruciate incision.

And this is a really important that the peritoneal orifice and the mesh orifice then align. So that way you don't have like a a third layer where the bowel can potentially Z or get kinked. And then you would bring the stoma through the anterior rectus sheath, and then you would bring it up through the skin.

So those four, that's how a retromuscular sugar baker, I think of it in my, in my hand, which is kind of a little bit of a combination of a keyhole and a sugar baker to where we've kind of affectionately call it a key baker. But that's kind of how we. we tend to do them. If you leave it in situ, rather than just taking the stoma down and bringing it through, you leave the stoma up, but you would then incise the peritoneum laterally again, as far as you could possibly allow it to go.

Now the stoma is still connected to the skin. You can be a little more aggressive here with

lateralizing the bowel. And then you have to then sew the peritoneum back together from starting lateral to medial. To allow your lateralization of the bowel, and then you lay in the mesh. And now what we do with that is we used to just let the mesh curl up on the, on the bowel.

But now we kind of slid it and tuck the tails back around the lateral way behind the stoma, which again provides kind of more lateral abdominal wall stabilization with mesh. But that's kind of the two, two ways that I think of it. So one of the issues with the sugar baker is you actually need a lot of bowel length to make sure that you can get that lateralization without tension.

So what are your options if your stoma bowel isn't really reaching either, either way? Yeah, I mean there are a couple of reasons that it might not reach. Sometimes it's just that the bowel hasn't been mobilized enough. So if you're looking at a left colostomy for instance, sometimes it will involve mobilizing say to get additional length on the bowel and the

mesentery itself.

And so it may be that either The retroperitoneal attachments of the bowel or the mesenteric blood supply to the bowel is the limiting factor. So I think determining, is it one of those things that's causing the problem that's preventing the bowel from being able to lateralize? Also similar for an ileostomy.

For an ileal conduit, it's a little bit different because it may be that the location of the ureteral This makes it that the conduit is too short to lateralize in that way. And if that is the case, that whether the bowel is too short to lateralize or say the conduit is too short or whatever it is, for me I'll audible to a keyhole in that case rather than cause further morbidity.

If I can easily repair the issue, such as mobilizing or even choosing a different segment of the bowel to bring up and resec, do a, you know, a little bit of a bowel resection, then I might opt for that to get a sugar

baker repair out of it. But if I cannot, I'll audible to a keyhole. The other thing to consider is that, you know, another reason that a stoma might not reach is not just because of the sugar baker length, but the length that is needed to traverse the subcutaneous tissue.

If the subcutaneous tissue is too deep, sometimes moving the stoma up on the abdomen can help with that because a lot of these patients where they have thick subcutaneous tissue that's located in the lower part of the abdomen so sometimes you can get away from that by moving the stoma up on the abdominal wall.

Yeah, the thing that really sucks if you don't have the length is oftentimes at that step of the operation your posterior sheath is already closed, your mesh is already in, and you're trying to judge. If it'll reach or not, and I will say I've left some that I've had that are too much tension, and I've been definitely burned by stoma retraction, mucocutaneous separation, leaking into a wound near the

stoma, so it just becomes, it can become really complex quickly post op, so just make sure before you leave the operating room you're happy with how it goes, and don't leave the operating room until you're happy.

I agree with that, and I think particularly if you're trying to force a sugar baker when you don't have enough length, you will pay for that, and I have absolutely been burned by that as well. In my case, I was burned by a mesh erosion into the stoma itself, so it was catastrophic. And what I would say is if I had it to do over again, in that case, if I couldn't get enough length, I would just change to a keyhole approach.

Yeah, and there is a recent randomized trial comparing retromuscular sugar baker and keyhole techniques together that don't feel like if you're doing a keyhole, you are doing a disservice to the patient and having higher recurrence rates because that's probably not, not the true story with the randomized data.

So, one, one unique situation you might get into that's certainly may change your operative plan is patients who either have

a WHOOP, Colostomy or loop ileostomy or a loop end, meaning that the side, kind of the side of the stone was matured and there's a dog ear or kind of a tail end of the stapled off side.

To the stoma. It's just really, yeah, kind of candy cane. Yeah that's, that's too, not a dog ear. Did I say dog ear? Candy cane. Candy cane. Depending on your dog. Ryan's dog, definitely dog ear. That, where there's a candy cane portion to the loop end, and so, just knowing that ahead of time can help you plan and anticipate where those bowels, bowels and things need to be.

And if we do encounter those here at the clinic, we do tend to just. , make those a clean end convert those to a clean end ileostomy or colostomy just at the same time as repair, which is, since you're there already, there's no sense in leaving that kind of bulk. Mm-Hmm. . One thing to consider when taking these patients to the operating room, whether you're going open or lap, it can be extremely difficult to

delineate the anatomy of the stoma itself.

The first thing to think about is what all is stuck in the peristomal hernia. And a lot of that information can be gotten from the CT scan. So trying to understand, particularly if there's a lot of visceral fat, it can be very difficult to understand if there's a lot of extra stuff stuck in the stoma trepanation.

So getting all of that down is important. And during that dissection, it's obviously of the utmost importance to avoid injury to the mesentery, but that can be extremely difficult technically. So you got to be kind of on the lookout for that when you're doing the dissection. The other thing is if you're planning to do a retromuscular repair, really, if you want to do a retromuscular repair with or without moving the stoma, you have to free the bowel and the mesentery circumferentially from the inside where it's leaving the abdominal wall.

So, usually there's a fair amount of redundant hernia sac there and that dissection can be technically very challenging. It can be difficult

exposure, but it's of the utmost importance that that entire thing is circumferentially dissected so that you have enough length on it, first of all, but second of all, so that you make sure that there's not other items that are still stuck out in the hernia sack.

And then after that, you know, if I'm going to move the stoma, I'll usually staple it off. flush with the abdominal wall from the inside to avoid getting any contamination in the operative field until I mature it wherever I'm going to bring it up again. So I'll do that early in the operation. I'll mobilize everything up, make sure that the stoma is circumferentially free, and then I'll staple it off and take the mesentery, say with an energy device to avoid additional bleeding.

So I think that's another little tip that can help. in the OR. Then you got to make sure that you remove the remnant stoma from where it's coming out of the skin. So there's usually the distal portion of the stoma that's still there and that thing must be dissected out completely and removed from the field.

But if all goes right, then you really minimize your contaminant burden within

the abdomen with that move. How do you prep the operative field for these and how do you exclude the stoma? What do you do for that? I'm, I'm probably a little bit more belts and suspenders than everybody, but I would say my, for my ileal conduits or urinary divisions, I place a Foley and inflate the balloon with five cc's of fluid to try to create a seal on the inside.

And then I, once the Foley is in, which I put in sterile before draping after prepping. And then I sterilely hook a Foley bag to the end of the catheter as it comes to the abdominal wall. It comes out of this conduit. But I would say there's still with that, there's leakage of urine that comes around that, which often drains out laterally because they're supine.

I then put a Ray Tec and stapled the Ray Tec to the skin just to kind of catch any additional urine that might come around, which works pretty well. It's not perfect, but it works pretty well. My

GI diversions, I close with a running O silk suture. Even if I'm planning on just leaving it in situ, I just close the mucosa together with a running, locking O silk.

And then I cover, and then I prep with Betadine. And then I cover that with Ray Tec and skin, staple the Ray Tec to the skin. So out of the things that that you guys have in your toolbox for approaching these repairs, we've talked about surgical considerations and approaches. We've talked about anatomical components and considerations.

What about the lasting of, like, your preferred mesh type for your lasting repair? What do you guys like to consider? What are, what are you thinking about? So there are obviously several different options, and it's a very common question that we get asked. I still would say, given all of the data out there surrounding this very difficult surgical process disease that uncoated polypropylene mesh is probably still your, the backbone and foundation of what you should use in these patients in the retromuscular space.

Obviously, you would need to have a coated construct for intraperitoneal placement, but

for the extra, extra peritoneum, I think an uncoated probably the most tried and true mesh construct for peristomals. Okay. . Now obviously there's biologics, biosynthetics, and was orbital synthetics, and all of those have a very attractive traits that may lend itself towards these more complex hernia diseases, particularly when you add in the degree of contamination that almost inevitably comes along with trying to prep and excluding the stoma during prep without it.

That usually being, at least for me, super successful. So some people would maybe advocate for some of those different mesh constructs to be used in this situation. And I would say that. Biologic mesh, while it has a great, in theory, has never really been proven to decrease recurrence rates. And to me, the added cost of biologics hasn't quite justified that use in that space.

And so I think, while it's not necessarily wrong to use biologic for peristomals, I do think from a durability standpoint, I would probably still prefer to

lean towards an uncoated polypropylene mesh. And the other mesh constructs that are out there, the ones that are kind of like hybrid meshes that have dissolvable coatings, but permanent weaves in the middle, or some that are absorbable synthetics that eventually go away long term, I will just tell you that it's great to study those and apply those in these settings, but don't I would still say those are still things that should to be, undergo a scientific investigation prior to becoming more of a standard of care in this space.

I agree. I mean, I think, Listen, at the end of the day, peristomal hernia repairs are very difficult, they have a very high recurrence rate and to some extent, the success of the repair certainly does revolve around the technique used, at least in great part. But I would also say the fundamental underlying problem is never resolved, which is that a stoma is coming through trepanation of the abdominal wall.

So, I would agree, mesh material wise I prefer to use a

bare uncoated polypropylene, usually something in the mid weight class for this type of repair. But to be clear for everybody out there who's wondering, you know, is a piece of mesh going to save you? Likely not. I think, honestly these patients have a high risk of recurrence and I commonly tell them, you know, the goal is to get you as far down the road as we can in time without having to have a re operation for a recurrence.

So for that, for me right now it's midway at bare polypropylene. Okay. Let's talk about some post operative considerations. So what are some of the common complications that you anticipate for this patient population that you try to counsel them preoperatively?

Great question. I would say the first thing that I always talk about for post op stuff when I discuss with them in pre op. is the recurrence rates, which I know it sounds a little bit silly, but I would say you need to set the expectation that these are very difficult hernias to repair, regardless of technique, regardless of mesh use that the recurrence rates all are

still extremely higher than a ventral hernia without a stoma.

So they need to have the expectation that there was a, there's a real recurrence rate associated with these. Of which is probably in the 15 to 30 percent range, if not longer, which is probably in the first two to three years after surgery. That would be a strong estimate based off of what I can remember off the top of my head for literature.

So the patients just need to know that. And then I also talk to them a little about symmetry. Because often times patients want to be flat, they want to be symmetric. And I always say, listen, with a stoma, you may, you're never going to be correct. that muscle, the rectus muscle, the stoma, goes to never function super great again.

There's always a little bit of asymmetry regardless of how good of a hernia repair I do. But reality, if you're doing the hernia repair for like stoma appliance issues, those things tend to be very well resolved and improved with hernia repair. So that's a great indication to do it. But, you know, setting that expectation about symmetry to me is also important.

I

would agree. And I would say that But as far as pouching after a peristomal hernia repair, I always warn the patients ahead of time, particularly if we're leaving the stoma in situ, that the area around the stoma may change in terms of its contour and the type of appliance that the patient may have to use.

So sometimes even though they've used the same appliance with great success for many years even. Once you do the repair, particularly if there was a lot of material or a lot of viscera stuck in the hernia, now you're going from convex to concave, and sometimes that means that you need a different kind of appliance.

So, I think the biggest thing is because it's such a personal issue and because it has to do with something that affects their everyday lives, I talk to them about that so they know what to expect, and I have a very low threshold to get the endostomy continence nurses involved. The other thing is that, as you mentioned, you know, it's hard to make sure that you avoid any

contamination throughout the entire case.

Obviously, we do our best with prepping and draping, but it is a contaminated case. And so there's always some additional risk for wound morbidity. I don't think that this greatly increases the risk for mesh infection, but at least superficial wound morbidity is always on the table for something that may happen to these patients.

Oh, some other things that come to mind are that, obviously because we have a piece of bowel that will be interfacing with a piece of mesh, and in our practice that will be a permanent synthetic mesh there is always the risk for long term mesh related complications requiring re operation. So that may include mechanical obstruction of the stoma by the mesh.

It might include erosion of the mesh into the stoma. Or loss of blood supply at the stoma, which we've seen once in our practice here where the mesh eroded into the mesentery of the stoma. So, I think mesh related complications where the mesh interfaces with the stoma should absolutely be discussed with the patient ahead of time as well.

The other thing I would just add about what we discussed previously about the keyhole, deciding between a keyhole and a sugar baker repair, which one is, one certainty is bowel length. I think the other thing that will influence that greatly for me is. what the patient needs to do with the stoma. So if it's a continent stoma, meaning that the patient has to instrument it to either get urine out or to, if they flush it with enemas or whatever, to have a content, a contingency to their stoma.

Those are ones you cannot sugar baker. You have to keyhole them. Otherwise whatever they're trying to get through the stoma to release it, that's it's going to become very, very difficult or if not impossible for them to do so. And then after that, you're looking at revising that stoma again, you know, after the fact.

So that's one. The other thing I would say is how much they need to be surveillance with endoscopy. Because if you sugar baker an ileostomy or a colostomy that somebody is getting a colonoscopy every

six months or every year or something, having them take that huge turn through the Z can be really, really difficult with a sugar baker.

And so oftentimes that will play, those, those things that will play a role if I decide about sugar baker keto as well. Just another unique thing about peristomals, I think. And one last thing to think about, if you are doing a peristomal hernia repair on a patient with a urinary reconstruction, if they are aneuric for any reason after surgery, that is a surgical emergency until proven otherwise.

And what I mean by that is that the obstruction of the stoma, either at the fascia or the level of the mesh or whether you sugar bakered it or whatever reason there is, a urinary conduit should always be draining urine. So if it is not, that requires immediate attention of the surgical team and immediate resolution because obviously the patient can then go into renal failure which a very bad complication if you're not careful.

So, that's something to look out for if approaching any type of

urinary stoma with a hernia. One thing that everybody needs to think about, you know, particularly if taking a patient to the operating room that has an ileal conduit. type of urologic reconstruction is that commonly we'll get a lupogram on these patients ahead of time before surgery to make sure that there is no stricture at the ureteral anastomosis.

This is something that you should be on the lookout for, particularly in patients that have had multiple admissions for urinary tract infections. Those are the patients who may have a stricture there. And sometimes that needs to be addressed at the time of the operation too because there's nothing worse than repairing the It's the peristomal hernia, and then come to find out that they've got a separate reason or nidus for infection.

So that's one thing to consider. And then post operatively, if a patient becomes aneuric after a urinary conduit peristomal hernia repair the first thing I would do would be pass a Foley or my finger to make sure that the stone was not obstructed at either the fascia or the mesh level.

If that's not the issue, then after that I would pursue more aggressive imaging to make sure that there's not an obstruction at the ureter or another mechanical obstruction as the cause for anuria or oliguria.

Yeah. I think I would just tack on to that as well that cause oftentimes if you preoperatively are getting a CT scan for somebody who's got a, an ileal conduit and they have hydro, it's always not clear if it's the ureteral anastomosis or it's the hernia. So oftentimes a hernia gets blamed, but in reality the hernia could just be an incidental finding and ureteral anastomosis is actually the cause of the hydro.

So that's why getting preoperative imaging and investigating of that is super important because once you do your tar and your peristalmal hernia repair and all your rest of your mesceral mesh, that is it, right? You want that to be the last operation that person has. So you need to plan out that surgery very, very well of which one is investigating the ureteral anastomosis through a lupogram.

in order to

prove to yourself and the patient that the anastomosis is okay. And if it does need to be revised, I have no issues with them coming at the time of surgery, re implanting the ureters, which often urology would do without any issues at all and that would still not change my, my choice of mesh or my style of repair.

Yep. Completely agree. So, thank you to Dr. Berboux and Dr. Beth for being here and talking with us today, from all of us here at Cleveland Clinic and from behind the knife. Dominate the day.