A parastomal hernia is a type of incisional hernia that develops near an ostomy, or stoma, where abdominal contents protrude through the abdominal wall defect created for the stoma. This complication is common, with occurrence rates reported to be as high as 50% within two years of stoma formation. Repairing this hernia is a complex surgical challenge due to the presence of the stoma and the high risk of recurrence. This article explores the reasons for surgical intervention and the strategies used to achieve a durable repair.
Understanding Parastomal Hernia and Indications for Repair
A parastomal hernia causes a noticeable bulge around the stoma, which can increase in size over time. Although many hernias are managed non-surgically, repair becomes necessary when the patient experiences significant symptoms. The primary indications for surgery include severe pain, difficulty maintaining a proper seal with the stoma appliance leading to leakage and skin irritation, or a negative impact on the patient’s quality of life. Urgent surgery is required if there are signs of bowel obstruction or strangulation. Strangulation is a life-threatening complication where the blood supply to the trapped bowel is cut off, requiring immediate surgical intervention.
Different Surgical Strategies for Repair
The choice of surgical approach depends on the hernia’s size, the patient’s overall health, and the presence of infection. A simple local repair involves returning the protruding tissue to the abdomen and closing the defect with sutures, known as primary closure. This method is associated with a high rate of recurrence, making it the least favored option for most parastomal hernias.
A more definitive strategy is stoma relocation, which involves moving the ostomy to a new site, often on the opposite side of the abdomen. This allows for complete closure of the original hernia defect and the creation of a new stoma in a healthier area of the abdominal wall. While effective, relocation is a more extensive operation that carries the risk of a new parastomal hernia forming at the new site, or an incisional hernia at the site of the original stoma closure.
Surgeons can perform the repair using either a traditional open approach or a minimally invasive laparoscopic technique. The open approach involves a larger incision, providing direct access to the hernia sac and surrounding tissue. The laparoscopic method uses small incisions and specialized instruments, often leading to a shorter hospital stay and faster recovery. Laparoscopic repair is generally preferred when feasible, but extensive scar tissue or an emergency situation may require conversion to an open procedure.
Mesh Reinforcement Techniques
Reinforcing the repair with surgical mesh is the standard of care to reduce the chance of recurrence. The mesh provides a scaffold for new tissue growth, strengthening the abdominal wall at the weakest point. The choice of mesh depends on the potential for contamination within the surgical field, since the stoma is an opening to the bowel.
Synthetic meshes, typically made from materials like polypropylene, offer permanent reinforcement but carry a higher risk of infection if placed in a contaminated area. Biological or absorbable meshes, derived from human or animal tissue, are used when there is a known risk of infection or contamination. These meshes are eventually absorbed by the body while promoting tissue integration, though they may offer less long-term durability than synthetic options.
The anatomical placement of the mesh is a precise decision that defines the repair technique. The mesh can be placed in an onlay position, situated over the fascia, or in a sublay position, underneath the muscle layer and above the posterior sheath. The intraperitoneal position, where the mesh is placed inside the abdominal cavity, is also commonly used in minimally invasive approaches.
Two principal mesh configurations are employed: the keyhole and the Sugarbaker techniques. The keyhole technique uses a piece of mesh with a central slit or hole that is wrapped circumferentially around the stoma. While straightforward, the cut in the mesh can become a point of weakness, potentially leading to recurrence. The Sugarbaker technique involves moving the bowel that forms the stoma laterally beneath the abdominal wall and then covering the entire hernia defect with a sheet of mesh without any central cut. This configuration is often favored, particularly in laparoscopic repairs, as it avoids creating a potential weak point in the mesh.
Post-Operative Care and Recurrence Risk
Recovery following parastomal hernia repair requires a dedicated period for healing and a gradual return to normal activities. Patients typically remain in the hospital for a few days, and a full recovery often takes six to twelve weeks. Pain management is a priority, and patients may be advised to wear an abdominal binder to provide support and reduce discomfort immediately after the operation.
The recovery process involves strict limitations on physical exertion, especially avoiding heavy lifting or any activity that significantly increases abdominal pressure. Straining can compromise the repair, and surgeons advise against lifting anything heavier than a small weight for the first six weeks.
Despite surgical advances, parastomal hernias have a notable risk of recurrence, which can range from low single-digit percentages to over 20% depending on the technique used. Patients minimize this risk by maintaining a healthy weight and avoiding chronic conditions that cause straining, such as chronic cough or constipation. Long-term follow-up with the surgeon is important for monitoring the repair and addressing any signs of a new bulge quickly.