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A simple diagram showing the port and colostomy placement in relation to laparoscopic abdominoperineal resection with extraperitoneal sigmoid colostomy and partial hepatectomy for rectal cancer accompanied by synchronous liver metastasis. A: 12-mm trocar. B: 5-mm trocar. C: Camera port. S: Colostomy.  : For rectal surgery.  : For hepatectomy.
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Extraperitoneal sigmoid colostomy was performed between the 5-mm trocars in the left lateral and iliac regions (Figure 1).
Abdominal CT revealed suspected small bowel herniation (arrow) at the left lateral region close to the extraperitoneal colostomy. Although it was not proven on any of the images, the CT images suggested the presence of an abdominal wall between the hernia and stoma (arrowhead).
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Based on this image finding, we diagnosed the patient with TSH (Figure 2).
Laparoscopic view. a: The hernia orifice (red line) over the 5-mm trocar site (blue line) in the left lateral region was located extremely close to the extraperitoneal colostomy (yellow line). b: A 20 x 15-cm SymbotexTM composite mesh (Covidien) covering the orifice fixed to the abdominal wall with AbsorbaTackTM (Covidien) via the double-crown method.
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We ensured that there were no abnormal findings indicating a hernia around the pathway of the extraperitoneal stoma (Figure 3).
Schematic illustration of this hernia. The hernia orifice matched the 5-mm trocar site, and the hernia sac spread from the parastomal site.
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We determined the hernia orifice to be the 5-mm trocar site, and based on intraoperative findings and preoperative CT, the hernia sac was located in the parastomal part (Figure 4). It was secured to the abdominal wall using AbsorbaTack  (Covidien) via the double-crown method (Figure 4).