A parastomal hernia is a common complication following ostomy surgery, which creates a stoma (a surgical opening on the abdomen) to divert waste. The condition involves the weakening of the abdominal wall muscles near the stoma site, allowing internal organs to push through. This is one of the most frequent long-term issues for individuals with an ostomy.
What is a Parastomal Hernia?
A stoma is a surgical opening, typically involving the small or large intestine, brought to the surface of the abdomen to allow waste to pass into an external collection pouch. Creating this opening requires an incision through the layers of the abdominal wall, including the fascial and muscle layers. This necessary incision creates a permanent area of structural weakness.
A parastomal hernia is a specific type of incisional hernia occurring immediately surrounding the stoma (the peristomal area). It involves the protrusion of abdominal contents, such as a segment of the intestine or fatty tissue, through the weakened muscle layers adjacent to the stoma’s opening.
The hernia is distinct from the stoma itself, as abdominal contents push around the exteriorized bowel. Severity varies, ranging from small bulges to large swellings prominent when standing or coughing. Since the stoma is routed through the abdominal muscles, the structural integrity of the area is permanently compromised, making parastomal hernias a frequent occurrence.
Common Signs and Symptoms
The most noticeable indicator of a parastomal hernia is a bulge or swelling around the stoma, which increases in size when standing, straining, or coughing. This swelling typically reduces when the person lies down. The physical presence of the hernia can cause a persistent, uncomfortable dragging sensation or a dull ache, especially after physical activity.
The condition often creates practical problems related to ostomy management. The change in abdominal contour makes it difficult to achieve a secure seal with the ostomy appliance, leading to issues with adhesion and frequent leakage. This poor fit can cause significant skin irritation and breakdown around the stoma.
In some cases, the hernia can change the stoma’s size or shape, sometimes making it appear retracted or sunken. A change in stoma output, such as alternating constipation or diarrhea, can signal that a segment of bowel is trapped within the hernia sac. Sudden, severe pain or a complete lack of stoma output requires immediate medical attention.
Understanding the Causes and Risk Factors
The development of a parastomal hernia stems from surgical factors and patient-related conditions that weaken the abdominal wall or increase intra-abdominal pressure. The initial surgical creation of the stoma provides the mechanical defect, as muscle and fascia must be divided. If the opening created in the fascia is too large, it provides less resistance and allows for easier protrusion of abdominal contents.
Patient-specific factors significantly contribute to the risk, primarily anything that increases pressure on the surgical site. Obesity is a major risk factor, as excess abdominal fat increases pressure. Chronic activities involving straining, such as heavy lifting, persistent coughing, or chronic constipation, repeatedly stress the weakened area. Connective tissue disorders or poor nutritional status can also impair the body’s ability to heal and reinforce the surgical wound. The risk generally increases over time, with many cases developing within the first few years after the ostomy procedure.
Managing and Treating the Condition
Management of a parastomal hernia begins with conservative, non-surgical strategies, especially when the hernia is small and causes minimal symptoms. A primary recommendation involves using specialized support garments, such as abdominal binders or hernia belts. These devices provide external compression to help contain the bulge, support the abdominal wall, and significantly improve comfort and aid in securing the ostomy appliance.
Lifestyle modifications are an important component of management. Maintaining a moderate body weight and avoiding activities that generate high intra-abdominal pressure, such as strenuous exercise or heavy lifting, can prevent the hernia from enlarging. Specialized ostomy appliances that are flexible or convex can also be used to improve the seal and manage leakage caused by the change in abdominal contour.
Surgical repair is typically reserved for cases where conservative methods fail to alleviate severe pain, or when serious complications arise, such as bowel obstruction or strangulation. Strangulation occurs when the blood supply to the trapped tissue is cut off, requiring emergency surgery. Elective surgery may be considered for persistent pain or intractable appliance leakage that significantly affects quality of life.
The surgical approach often depends on the hernia’s size and the patient’s overall health. Options include primary repair, which involves suturing the defect closed, but this has a high recurrence rate. A more common technique is mesh repair, where synthetic or biological mesh material reinforces the abdominal wall around the stoma. In complex cases, a surgeon may relocate the stoma to a new site on the abdomen, closing the original site to prevent recurrence.