eTEP PAULI IN A TYPE IV PARASTOMAL HERNIA

Abstract Video abstract A 63-year-old male with a history of abdominoperineal resection due to rectal adenocarcinoma presenting discomfort in a reducible 6 cm parastomal hernia (PSH) & M3W1 incisional hernia (Type IV PSH). We propose a full endoscopic minimally invasive extraperitoneal modified Sugarbaker approach (e-TEP Pauli). A 2 cm incision on the right subcostal region is made, opening the anterior rectal sheath, medializing the right rectus muscle. A dissection balloon was introduced to release the retromuscular space on the right side. Two more trocars were inserted in the right hypocondrium and right iliac fossa (10 mm, 5 mm respectively). The medial aspect of the right posterior rectus sheath (PRS) was incised, and the preperitoneal dissection was performed superficial to the Falciform ligament, doing the crossover above the umbilicus. The hernia was reduced, connecting both right and left retrorectus spaces. A modified posterior components separation (TAR) is performed, sectioning the aponeurosis of the transverse muscle (TM), accessing the preperitoneal space laterally without sectioning the TM. The colonic stump is released and reintroduced. The anterior defect is closed maintaining adequate passage of the colonic stump, and is fixated with sutures to the lateral abdominal wall. The peritoneal orifice is sectioned to lateralize the stump. The peritoneum and PRS are closed around the colonic stump. A PVDF-mesh covering both retrorectus and preperitoneal spaces is placed. A drainage is place and removed 24 h after. He was discharged 24 h after. In the CT 6 months after surgery, no abdominal wall defect was observed and pain and esthetic results where satisfactory.