Parastomal Hernia Repair in Bricker Type Urinary Diversion Using the Modified Pauli Technique: A Case Report

Abstract Introduction The incidence of parastomal hernia (PH) associated with Bricker ileal urinary diversion is approximately 20%. Surgery becomes necessary in the presence of symptoms or development of complications. Clinical case A 77-year-old woman with a Bricker urinary diversion following radical cystectomy presented to the emergency department with 72 hours of evolving obstructive symptoms, coupled with a large PH featuring incarcerated bowel. A CT scan confirmed complete intestinal obstruction. Urgent surgery was conducted, revealing ileum incarceration without perforations. Reduction of the intestinal content was performed, restoring viability. Transversus abdominis release (TAR) around the stoma was executed, followed by the placement of a retromuscular progrip mesh using the Pauli technique. The patient was discharged after 8 days without complications. Discussion The surgical treatment of PH remains controversial, lacking a consensus as the most effective technique. We opted for modified Pauli technique, involving retromuscular dissection, subsequent components separation via TAR and mesh repair according to the Keyhole technique. This combination leverages the advantages of each of procedures to reduce the recurrence risk: retromuscular mesh placement physiologically pushing the wall, utilization of wider prostheses reinforcing a larger surface area, complete mesh contact with the wall facilitating integration around the defect, and direct stoma exit without the need for repositioning. Conclusions The modified Pauli technique with Keyhole mesh placement, while demanding, can provide advantages in emergency surgery without causing significant postoperative complications.