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360 P.R. Carter and K.A. LeBlanc
– – – –
3.5% 0.7% 3.2% 0.9%
% 0.9% 2.6% 1.2% 2.9%
a
0% 1.5
– – – – – –
2% 5% 0% 4%
– – – – – – – – – –
1.1% 1.1%
10% 2% 4.2% 0%
– – – – – –
10% 2%
b
– – – – – – – – – –
0% 4.7%
– – – – – – – –
%
1.1% 0% 0% 6.6
– – – – – – – –
0% 6.6%
Open Lap Open Lap Open Lap Open Lap Open Lap Open Lap Open Lap Open Lap Open Lap
Table 22.2 Postoperative complications
Complications Ballem [ 33 ] Bencini [ 34 ] 2003 Bencini [ 35 ] 2009 Olmi [ 10 ] Pringe [ 7 ] Lomanto [ 9 ] McGreevy [ 12 ] Forbes [ 11 ] Pierce [ 8 ]
Enterotomy – –
– – – – – –
Ileus – –
Fecal
obstruction
– – – – – – – – – – – – – –
Mesh Infxn/
removal
– – – – – –
Neuralgia – – – – – –
Pulmonary
9% 16% 10% 14% 3% 11% 1.1% 7% 33% 17% 6% 10% 4.2% 3% 15.5% 11.7% 12% 12.1%
– – – – – – – –
embolism
Seroma
Urinary
9% 7.5% 12% 0% 8% 0% 8.2% 1.1% 16.7% 3.3% 6% 4% 8.4% 0% 10.1% 1.5% 10.4% 1.3%
a
retention
Wound Infxn
Pre-existing procoagulant disorder
Unrecognized
b
[ 21 ] . Should an enterotomy occur and is recognized, the
injury should be repaired, of course. The next decision is
whether or not to proceed with the repair of the hernia itself.
The use of a prosthesis is to be avoided in conventional
teaching but there is a growing opinion that the use of lower
weight meshes might be considered in this situation as these
seem to be less prone to infection. A primary repair of the
hernia will be associated with a high risk of recurrence.
Therefore, many experts recommend that the primary repair
be avoided and the patient be returned to the operating room
in several days [
41 ] . With the introduction of biologic prod-
ucts for the repair of the hernias in contaminated fi elds, perhaps these could be used in this situation. This has not been
reported but it has been done in some cases.
The overall cost of LIVH has been shown to be equivalent
with open mesh repair. A single institution prospectively collected data on 884 incisional hernias. There was no statistical
difference in overall hospital cost for LIVH when compared
to open mesh repair. LIVH was shown to have shorter length
of stay, though operating time and cost of supplies were
higher in LIVH. LIVH costs $6,725 compared with $7,445
for open mesh repair in total hospital costs and postoperative
encounters [ 42 ] .
Obesity and LIVH
Obesity has been shown to be a major factor in hernia recurrence. In a study of 160 patients, obesity was compared to
other risk factors for hernia recurrence such as smoking, diabetes, steroid use, and pulmonary disease. Obesity was the
strongest predictor for hernia recurrence. Patients with a body
mass index (BMI) of 38 were 4.2 times more likely to have a
recurrent hernia in comparison to a patient with a BMI of 23
[ 18 ] . Congruent results were identi fi ed in a multi-institutional
study of fi ve academic centers. This retrospective review
found the recurrence rate to be signi fi cantly higher in morbidly obese patients with an odds ratio of 4.3 [
Though some report a higher recurrence rate in obese
patients, LIVH is safe and effective in this population of
patients. LIVH has been shown to have less risk of wound
complications, greater identi fi cation of multiple occult
defects and wider mesh overlap. In a review of 168 patients
at a single institution, perioperative complications after
LIVH were not found to be statistically different from nonobese patients. Recurrence rates were related to defect size
and size of mesh rather than obesity [
repair is even promoted during laparoscopic bariatric surgery
when concurrently identi fi ed. In patients who did not have
their ventral hernia repaired during laparoscopic gastric
bypass, there was an increased risk of intestinal incarceration
during patient follow up [ 44 ] .
17 ] .
43 ] . Ventral hernia
36122 Laparoscopic Incisional and Ventral Hernia Repair
Conclusion
LIVH has a proven track record as an effective, safe, and
durable option for ventral hernia repairs. There is general
consensus that LIVH has comparable recurrence rates to
open mesh repair, if not less risk of recurrence as seen in
some prospective trials. Wound complications and mesh
infections occur infrequently. Hospital stay is shortened and
increasingly, LIVH is becoming the fi rst and only attempt at
a disease that is commonly identi fi ed in 10–20% of postlaparotomy patients [
1, 5, 19, 45 ] .
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362 P.R. Carter and K.A. LeBlanc
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resource utilization for 884 consecutive cases. Surg Endosc.
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for laparoscopic ventral hernia repair between nonobese and morbidly obese patient populations. Surg Endosc. 2008;22:2244–50.
44. Eid G, Mattat S, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should
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Parastomal Hernia
Leif A. Israelsson
2 3
Spontaneous ostomies occurring after incarcerated and
fi stulated abdominal wall hernias and after trauma have been
reported since ancient times. A colostomy as a medically
useful procedure was fi rst suggested by Littre in 1710. The
fi rst successful colostomy was performed by Duret in 1793
on an infant with colonic obstruction due to an imperforate
anus. Today creating an ostomy is a common surgical procedure utilized in both elective and emergent situations as well
as by an open or a laparoscopic technique. This development
has been greatly facilitated by the improvement of modern
stoma bandages that nowadays enable an easy and reliable
stoma care. Unfortunately the development of parastomal
hernia is a very frequent complication and Goligher even
considered some degree of herniation as almost inevitable
after colostomy formation [ 1 ] .
Parastomal hernia may present as problems of stoma
care, dif fi culty with appliances or irrigation, a signi fi cant
cosmetic deformity—or as straightforward complications of
a hernia with intestinal obstruction or strangulation. The
presence of a large protrusion itself may make repair a
necessity irrespective of its other side effects (Fig. 23.1 ).
Parastomal hernia develops in 30–50% of patients supplied with an ostomy and one-third of these demand repairs.
After suture repair or relocation of the stoma recurrence
rates are unacceptably high. With open or laparoscopic
mesh repairs considerably lower recurrence rates are
reported. There are no randomized trials or long-term
follow-up studies available reporting results with these various techniques for parastomal hernia repair.
In randomized trials a prophylactic prosthetic mesh placed
in a sublay position has reduced the rate of parastomal hernia. In nonrandomized studies a prophylactic onlay, sublay,
or intraperitoneal onlay mesh (IPOM) has also been associated with low herniation rates.
L. A. Israelsson (*)
Department of Surgery , Sundsvall Hospital , Sundsvall , Sweden
e-mail: leif.israelsson@lvn.se
De fi nition of Parastomal Hernia
Pearl de fi ned parastomal hernia as an incisional hernia
related to an abdominal wall stoma [
de fi nition used at follow-up examination was actually given
in only one report and then parastomal hernia was de fi ned as
a palpable cough impulse at the ostomy site [ 3 ] . Beginning in
2004 and thereafter many authors have reported the de fi nition
used and have then regarded any protrusion in the vicinity of
the stoma as a herniation [ 4– 11 ] . With a parastomal hernia
detected according to this de fi nition, patients have been demonstrated to have a poorer quality of life than matched controls, so the de fi nition appears clinically relevant [ 11 ] .
A CT scan has in some studies been added to the clinical
examination at follow-up and the radiological de fi nition then
used was of any intra-abdominal content protruding along
the ostomy [ 4, 7, 8 ] . However, the correlation between her-
niation found at clinical examination and at CT scan has in
these reports not been very strong. Thus, herniation found at
clinical examination may not be present at a CT scan and
vice versa.
Without providing the de fi nitions used it has in several
reports been differentiated between parastomal hernia and
stoma prolapse [
nia was de fi ned as a hernia beside the stoma, and stoma prolapse as an eversion of the stoma through the abdominal wall
[
19 ] . It is not clear how to differentiate between herniation
and prolapse at clinical examination or with a prolapse present how to exclude a concomitant parastomal hernia. Many
authors may have regarded both entities as a parastomal hernia at follow-up examination. This does not seem unreasonable since both entities, however they are de fi ned, certainly
represent undesired complications after stoma formation.
The anatomy of the herniation is variable. Parastomal her-
nia has by Kingsnorth been classi fi ed into four subtypes [ 20 ]
23.2 ):
(Fig.
1. An interstitial type with a hernia sac within the muscle/
aponeurotic layers of the abdomen
2. A subcutaneous type with a subcutaneous hernia sac
12– 18 ] . In a Cochrane report parastomal her-
2 ] . Before 2004 the
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_23, © Springer Science+Business Media London 2013
363
364 L.A. Israelsson
Incidence of Parastomal Hernias
The rate of parastomal hernia is reported to occur within the
Fig. 23.1 A large parastomal hernia presenting problems of stoma
care, dif fi culty with appliances and a signi fi cant cosmetic deformity
3. An intrastomal type in ileostomies with a hernia sac
between the intestinal wall and the everted intestinal
layer
4. A perstomal type or prolapse with the bowel prolapsing
through a circumferential hernia sac enclosing the
stoma
This classi fi cation de fi nes the type of herniation accord-
ing to the position of the hernia sac. A circumferential hernia
sac within the stoma is consequently regarded as a parastomal hernia of the perstomal type or prolapse. The classi fi cation
has not been used in clinical studies as it is dif fi cult to distinguish these types of parastomal hernias by physical examination [
5 ] .
It is very dif fi cult to compare herniation rates between
different clinical reports since there has been no uniform
de fi nition of parastomal hernia. Also the rate of parastomal hernia increases with time, so herniation rates cannot
be compared between reports with different time to
follow-up. Follow-up examination should be no less than
12 months after the index operation, although parastomal
hernias still develop after 5–10 years following ostomy
formation [
21 ] .
Currently the practice is that parastomal hernia is de fi ned
as any protrusion or bulge adjacent to the stoma—detected
with the patient supine with elevated legs or while coughing
or straining when erect. With a CT scan added to the clinical
examination parastomal hernia is de fi ned as any intraabdominal content protruding along the ostomy.
very wide range of 5–81% [
variation is probably very much related to different de fi nition
of herniation being used as well as differences in time
between the index operation and follow-up examination.
Due to the lack of a uniform de fi nition of parastomal hernia
and the variable follow-up time in different reports, the true
rate of parastomal hernia can only be estimated. With a more
uniform approach during the last decade the rate of parastomal hernia reported after 12 months has been closer to 50%.
Thus, available data indicate that 1 year after stoma formation the rate of parastomal hernia is at least 30% and probably close to 50% in general surgical practice. The rate
increases during the following 5–10 years. Thus, parastomal
hernia is a major clinical problem.
The rate of herniation has been suggested to be lower after
an ileostomy than after a colostomy. Such a difference must
be questioned, however, as it has not been perceived in a
number of studies [ 3, 12, 29 ] . The proportion of parastomal
hernias occurring after ileostomy using the Bricker diversion
is similar to the reported rates using other ostomy techniques,
since rates of 5–65% have been reported [ 30– 36 ] .
Loop ileostomies and loop colostomies probably produce
similar rates of parastomal herniation [ 19, 37, 38 ] . Hernia
rates with loop stomas cannot easily be compared with end
stomas since follow-up time is often shorter with loop
stomas. The shorter follow-up time is due to loop stomas
often being intended as temporary and bowel continuity is
then often restored. A loop stoma may also be utilized as a
palliative means in patients with malignant disease and short
survival time after stoma formation.
Enterostomas were previously sometimes brought out
through the laparotomy wound, but this produced disastrous
results in terms of infection, wound dehiscence, and herniation
1, 39– 41 ] . An extraperitoneal construction of the stoma has
[
been tried in order to reduce the rate of parastomal hernia [
This was in two retrospective studies associated with a lower
rate of parastomal herniation than the conventional route. These
results have been challenged by others though, and the technique does not seem to have become widely used [ 20, 42 ] .
To bring out the stoma through the rectus abdominis muscle has in two retrospective studies been associated with a
lower rate of parastomal hernia than if brought out lateral to
the muscle [ 25, 43 ] . Four other retrospective studies did not
con fi rm these fi ndings [ 3, 26, 27, 44 ] . There are no randomized studies available to settle this matter, but it is nevertheless probably wise to bring out enterostomas through the
rectus muscle. This is obviously not associated with any disadvantages and placing the stoma as close to the midline as
possible facilitates patients’ stoma care.
3, 12, 15– 18, 21– 28 ] . This broad
1, 27 ] .
36523 Parastomal Hernia
Fig. 23.2 There are four subtypes of parastomal hernia. ( a ) Interstitial.
With a hernial sac lying within the muscle/aponeurotic layers of the
abdominal wall. This may contain omentum, small or large intestine.
In these cases the stoma is asymmetrical and is edematous and cyanotic if its vascular supply is compromised. ( b ) Subcutaneous. With
herniation alongside the stoma with a subcutaneous sac containing
omentum or bowel. This is the commonest form of paracolostomy her-
Making a too large opening in the abdominal wall for the
ostomy is often claimed to be the main risk factor for the
development of parastomal hernia. There is actually no clinical data to support this assumption, but it nevertheless
appears wise to make the opening just large enough to allow
the bowel to pass through. Surgeons probably do not intentionally create a disproportionately large opening in the
abdominal wall. A large opening and hence a possibly higher
proportion of herniation may be more related to a bulky
bowel necessitating a large opening. Fixating the mesentery
or suturing the bowel to the aponeurosis has been attempted
as means to lower herniation rates. Such measures can be
disregarded as they have not had any effect on the rate of
parastomal hernia developing [ 12, 27, 28, 45 ] .
Other risk factors for parastomal hernia formation which
should be taken into consideration include wound infection,
old age, obesity, corticosteroid use, chronic respiratory disorders, and malnutrition [
1, 20, 44, 46, 47 ] .
nia and not infrequently colon situated just proximal to the stoma is
found in the sac. ( c ) Intrastomal. This is a problem of spout ileostomies
only. A loop of intestine may herniate alongside the stoma and lie
between the emergent and the everted layer of the stoma. ( d ) Perstomal
or prolapse. A prolapsed stoma contains a hernial sac within itself;
other viscera, especially small gut, can enter this sac and even become
strangulated
Prevention of Parastomal Hernias
The most promising results in the attempt to prevent the
development of parastomal hernia have been with a prophylactic prosthetic mesh placed at stoma formation. There are
two randomized controlled trials available that together have
randomized 108 patients to either a conventional enterostomy through the rectus abdominis muscle or to the same
procedure with the addition of a mesh placed in a sublay
position [
hernia rate after 12 months of 10% with a prophylactic mesh
and 45% without a mesh. One of these trials has also reported
results after 5 years, and at that time the herniation rate was
13% with a prophylactic mesh and 81% without a mesh [ 21 ] .
This encouraging effect on the rate of parastomal hernia with
a prophylactic mesh was achieved without any increased rate
of infection or any complications related to the mesh. In particular no infection of the mesh occurred.
8, 23 ] . Taken together, they report a parastomal
366 L.A. Israelsson
Fig. 23.3 Steps taken when placing a prophylactic mesh at stoma formation. ( a ) A circular excision of the skin is made and it is dissected
through the subcutaneous tissue down to the anterior rectus aponeurosis. A cross is cut in the aponeurosis above the center of the rectus
abdominis muscle. ( b ) Corresponding to the stoma site peritoneum and
the posterior rectus sheath is opened along the midline for a length of
more than 10 cm. Dissection is continued to the lateral border of the
rectus muscle in the avascular plane dorsal to the rectus muscle.
( c ) A mesh 10 by 10 cm with a cross cut in its center is placed in the
It may in view of the similarities between incisional hernias
and ostomies appear rational to use a prophylactic mesh when
creating a stoma. An incisional hernia is de fi ned as intraabdominal contents protruding through a defect in the abdominal wall. In constructing an ostomy the surgeon creates a
defect in the abdominal wall for the bowel to pass through,
which according to the de fi nition produces a hernia. Therefore,
the high rates of parastomal hernia encountered without a prophylactic mesh are perhaps not surprising. If ostomies are
regarded as intentionally created hernias, it seems logical that
parastomal herniation can be prevented in the same way as
incisional hernias are repaired, i.e., with a mesh.
In the randomized trials employing a prophylactic mesh
in open surgery, the abdominal cavity was accessed through
the midline (Fig.
23.3 ). The skin at the stoma site was grasped
with a clamp and a circular excision of the skin was made.
After dissection through the subcutaneous tissue a cross was
cut in the anterior rectus sheath.
Corresponding to the intended stoma site, peritoneum and
the posterior rectus sheath were opened along the midline for
a length appropriate to contain a mesh of 10 by 10 cm.
Dissection was continued in the avascular plane dorsal to the
rectus muscle until the lateral border of the muscle was
reached.
A partly absorbable low-weight large-pore mesh was cut
to 10 by 10 cm and a cross was cut in its center—just large
enough to let the bowel pass through. The mesh was placed
in the retromuscular plane created and the upper and lower
lateral corners were anchored to the dorsal rectus sheath with
single absorbable stitches.
plane created. The lateral corners of the mesh are anchored to the dorsal
rectus sheath with single stitches. ( d ) The bowel is brought out through
the opening in the dorsal rectus sheath, the cross cut in the mesh, the
split in the rectus muscle, the cross cut in the anterior rectus sheath, and
the skin opening. ( e ) The medial corners of the mesh are anchored as
the running suture in the anterior rectus aponeurosis incorporates also
peritoneum and the mesh. Along the mesh every other stitch in the
aponeurosis includes peritoneum thereby averting bowel coming into
contact with the mesh
Peritoneum and the dorsal rectus sheath were then opened
by a cross incision at the intended stoma site. The stapled
bowel end was fi rst brought out through the opening in the
dorsal rectus sheath and then through the opening in the
mesh. The length of the bowel and the size of the opening in
the mesh could then be checked and adjusted. Lastly the
bowel was brought out through a split made in the center of
the rectus muscle and through the openings previously made
in the anterior aponeurosis and skin. The bowel was opened
and sutured with a running absorbable mono fi lament suture
with stitches placed 2–3 mm from the skin edge and with
seromuscular bites in the bowel.
The medial corners of the prophylactic mesh were
anchored and measures were taken to prevent the mesh
unnecessarily coming into contact with abdominal contents.
This was accomplished when closing the midline incision
with a continuous suture technique using a slowly absorbable or nonabsorbable mono fi lament suture in the anterior
rectus aponeurosis. Then the medial upper and lower corners
of the prosthetic mesh were anchored as the running suture
in the aponeurosis incorporated also the mesh and peritoneum. Along the length of the mesh every second or third
stitch in the aponeurosis also included peritoneum—thereby
preventing bowel from coming into contact with the mesh.
A low-weight large-pore mesh with a reduced polypropylene content and a high proportion of absorbable material
in a sublay position at the primary operation has reduced the
rate of parastomal hernia in two randomized trials.
Experiences with a prophylactic mesh used in routine surgical practice have been reported by Jänes. In 93 consecutive
36723 Parastomal Hernia
Fig. 23.4 Steps taken when placing a prophylactic mesh at laparoscopic stoma formation. ( a ) A circular excision of the skin is made
and it is dissected through the subcutaneous tissue down to the anterior rectus aponeurosis. A cross is cut in the aponeurosis above the
center of the rectus abdominis muscle. ( b ) The rectus muscle is split
and with the index fi nger and a space is created bluntly in the avascular plane dorsal to the rectus muscle. ( c ) A mesh 10 by 10 cm is
inserted via the skin opening. ( d ) The mesh is with the index fi nger
ostomies most patients could be provided with a prophylactic mesh in a sublay position. In less than 10% of patients a
mesh could not be utilized due to severe scarring of peritoneum or the abdominal wall after previous surgery.
Emergency stomas in severely contaminated abdomens are
probably at particularly high risk of developing a parastomal
hernia. In dirty wounds with fecal peritonitis a prophylactic
mesh was used in 19 patients and no infection of the mesh
occurred in these patients. The rate of surgical site infection
was actually lower in the group of patients provided with a
mesh than in others. The higher rate of wound infection when
a mesh was omitted was probably an effect of patient selection or some other bias, but it seems safe to conclude that a
prophylactic low-weight large-pore mesh can be placed in
severely contaminated environments.
Ostomies are sometimes formed by a laparoscopic
approach. Dissection and division of the bowel is then performed laparoscopically and the bowel is brought out
through an opening made in the abdominal wall with an
open technique. There is no reason to assume the rate of
spread out and positioned into the sublay position in the retromuscular space. ( e ) The sigmoid colon is held with a laparoscopic clamp
close to the peritoneum at the intended stoma site. The peritoneum is
then opened and as the abdomen exsuf fl ates the colon is grabbed with
a clamp inserted through the skin opening. The sigmoid colon is gently pulled through the mesh and the layers of the abdominal wall. ( f )
A running mono fi lament absorbable suture attached the bowel to the
skin
parastomal hernia to be lower with a laparoscopic technique than with an open. Thus, there is an indication for a
prophylactic mesh to be used when stomas are created with
a laparoscopic technique.
The laparoscopic dissection starts by mobilizing the
bowel and creating an appropriate length of the bowel before
it is divided with a cutting linear stapler (Fig. 23.4 ). With an
open technique the skin at the stoma site is grasped with a
clamp and a circular excision of the skin is made. After dissection through the subcutaneous tissue a cross is cut in the
anterior rectus sheath and muscle fi bers are split in the center of the rectus muscle. With the index fi nger through this
opening blunt dissection creates a space in the avascular
plane dorsal to the rectus muscle. A low-weight large-pore
mesh is cut to a 10 by 10 cm and is pushed through the skin
opening with the index fi nger positioning it in the retromuscular space created. A cross is cut in the center of the mesh
and peritoneum. As peritoneum is opened the abdomen will
exsuf fl ate. The bowel end that is held close to the opening
with a laparoscopic clamp is then extracted through the
368 L.A. Israelsson
mesh with a clamp inserted through the skin opening. This
method has produced similar rates of parastomal hernia
(10%) in 20 consecutive patients as with a prophylactic
mesh utilized in open surgery.
There are also a number of clinical reports with the use of
a prophylactic mesh in nonrandomized studies. In 1986
Bayer was the fi rst to place a prophylactic mesh in a sublay
position and reported no recurrence in 43 patients with up to
4 years of follow-up [
any recurrence in 18 patients within 6–28 months [ 9 ] . With
a prophylactic mesh placed in an onlay position Gögenur
reported two parastomal hernias within 2–26 months in 24
patients [ 49 ] . A mesh was designed especially to be used as
an IPOM with a fl at portion and a funnel arising for the
bowel to pass through. With this mesh as a prophylactic
mesh in an IPOM position Berger reported no parastomal
hernias or any other complications in 22 ostomies within
2–19 months [ 50 ] .
48 ] . Also Marimuthu did not report
Principles of Surgical Management of Parastomal Hernias
Surgical repair has been reported to be indicated in about
30% (11–70%) of patients with a parastomal hernia [ 5 ] . An
accurate diagnosis and assessment of the anatomy of the
hernia is essential. Therefore, the patient must be examined
(a) recumbent and relaxed; (b) recumbent with the muscles
tense—most easily achieved by elevating their legs; (c) in
the erect position; and (d) in the erect position with the muscles tense. Investigation of the detailed anatomy with CT
scanning is useful to delineate large parastomal defects in
the abdominal wall and their relation to any concomitant
incisional hernia. CT scanning can also detect small impalpable defects around ileostomies that present with dysfunction [ 51 ] .
An accurate assessment of the anatomy of the hernia
should be made. Alternative stoma sites should be considered if relocation of the stoma is needed. Care must be taken
if a decision to resite a stoma is made—the help of a stoma
care nurse (enterostomal therapist) is invaluable.
The patient who has had cancer surgery must be screened
for recurrence before surgery is advised. Similarly, it is prudent to exclude recrudescent in fl ammatory bowel disease
before undertaking operation in patients with ileostomies
although it should be noted that the risk of para-ileostomy
herniation is similar in patients with ulcerative colitis and
Crohn’s disease. An additional consideration that has become
more commonplace is the life expectancy of the patient. An
increasing number of patients of an advanced age are being
seen with multiple medical problems that add to the risk of
general anesthesia. If these illnesses will signi fi cantly shorten
the life of the patient (e.g., less than 2–3 years) or if these
prohibit anesthesia, then one may not wish to proceed if there
is no immediate need for surgical intervention.
Surgery is imperative in all cases of intestinal obstruction
or strangulation related to parastomal hernia. Urgent emergency surgery is also absolutely indicated in all cases of
paracolostomy hernia where perforation has occurred during
irrigation.
Surgery is the treatment of choice when a parastomal hernia causes abdominal wall distortion and dif fi culties with
fi tting an appliance or irrigating a stoma. Surgery should also
be considered if the stoma has become out of the patient’s
range of vision or if its site on a hernia bulge makes it unmanageable to elderly patients, especially those with arthritis.
The dis fi gurement caused by a bulging parastomal hernia
may warrant surgery for cosmetic reasons. In special circumstances, the repair may need to be accompanied by an
abdominoplasty to permit a good fi t of the appliance. In some
instances local liposuction at the stoma site may reduce problems with stoma care.
Contraindications to surgery include such general problems as cardiorespiratory failure, recurrent Crohn’s disease,
extreme obesity, disseminated malignancy, or a short life
expectancy from any disease process.
Preoperative cleansing of the colon is probably not indicated when repairing parastomal hernias. Randomized trials
have shown that in colonic surgery there is nothing to be
gained by subjecting patients to exhausting preoperative
colonic cleansing [
concerning parastomal hernia repair speci fi cally, but it seems
reasonable to extrapolate fi ndings in general bowel surgery
into this fi eld. Similarly there are no speci fi c studies at hand
concerning the use of antibiotic prophylaxis, but it is probably wise to administer prophylactic antibiotics adhering to
the same principles that have been shown to be bene fi cial for
bowel surgery in general.
52 ] . There is no similar trial available
Repairing Parastomal Hernias
There are several reports on attempts to repair parastomal
hernias by a local procedure. The stoma is then mobilized
locally, the peritoneal sac identi fi ed and its contents reduced,
and the peritoneum is closed. The musculo-aponeurotic
defect is closed with nonabsorbable sutures in an attempt to
narrow the aperture. Results have been very poor and the
method today must be regarded as obsolete. Local aponeurotic repair should not be performed since it produces an
unacceptable high recurrence rate reported in the range of
50–76% [ 42, 47, 53– 56 ] .
Stoma relocation either with formal laparotomy or with
limited transperitoneal transfer of the stoma has also been
tried when treating parastomal hernias. However, relocation
of the stoma into another quadrant produces a recurrence rate
36923 Parastomal Hernia
Fig. 23.5 Repairing parastomal, the mesh can be placed in an onlay,
an inlay, a sublay, or an intraperitoneal onlay position. ( a ) An onlay
mesh is placed anterior to the anterior rectus aponeurosis. The mesh
overlap must be considerable (5–10 cm) and the mesh fi rmly fi xated
to the aponeurosis. ( b ) An inlay mesh fi ts the abdominal wall defect
and is sutured to wound edges. This method produces inferior results.
at the new site that is at least as high as after the primary
enterostomy and recurrence rates of 24–86% are reported
[ 47, 53, 55, 57, 58 ] . If the stoma is relocated a second time,
the recurrence rates are further increased [ 47 ] . Caution
should be exercised when considering relocation of a stoma
into a quadrant on the same side of the abdominal wall since
this is associated with a higher risk of recurrence [ 55 ] .
A matter of concern after relocation of an ostomy is that
the defect in the abdominal wall at the parastomal hernia site
may be very large. Suture repair of the defect has produced a
high rate of incisional hernia at this site and Cingi reported
six hernias in 23 patients on physical examination and in 11
detected with ultrasound [ 22 ] . Thus, the abdominal wall
defect at a parastomal hernia site must—as with all other
large abdominal wall defects—be repaired with a mesh
technique.
Relocating the stoma into another quadrant is possibly a
better option if a prophylactic sublay mesh is placed at the
new site. This can be done in combination with a sublay
mesh repair of the abdominal wall defect at the primary
stoma site. This method has been reported in one nonrandomized series with no recurrence detected in 13 patients
after 12 months [ 59 ] .
Mesh Repair of Parastomal Hernias
There is no doubt that mesh repair has become a well-established method for repairing incisional hernias and is now
evolving as the method of choice also for repairing parastomal hernias. Meshes can be placed in an onlay, an inlay, a
sublay, or an intraperitoneal onlay position (IPOM)
23.5 ). The mesh must be placed with considerable
(Fig.
( c ) A sublay mesh is placed dorsal to the rectus muscle and anterior to
the posterior rectus sheath. The mesh overlap must be at least 5 cm.
( d ) An intraperitoneal onlay mesh (IPOM) is placed on the perito-
neum from within the abdominal cavity. The overlap must be more
than 5 cm, and the mesh surface facing the abdominal cavity must not
cause adhesions
overlap and in all directions extend at least 5 cm beyond the
edge of the abdominal wall defect. Clinical reports consistently state better results with mesh repair than with suture
repair or relocation of the stoma. As of yet randomized studies comparing mesh techniques and other techniques for the
repair of parastomal hernias are lacking as is also long-term
follow-up.
For mesh repair of parastomal hernias all available types
of meshes have been tried and results have been reported.
This includes nonabsorbable, absorbable, partly absorbable,
and acellular collagen matrix meshes. Polypropylene meshes
and low-weight large-pore meshes can be placed in a contaminated environment without major complications [
6, 60, 61 ] .
There is a risk of inducing a major in fl ammatory tissue
response when placing mesh in contact with bowel, and this
may cause fi stula formation, adhesions, and septic complications. With the IPOM technique a mesh constructed in two
layers is therefore usually used. The surface facing the
abdominal contents is of a nonreactive material so that adhesions are not formed. When ePTFE is used for this nonadhesive surface, there is a high risk of infection in contaminated
areas and if an infection occurs the mesh must be removed.
Placement of an onlay mesh in the subcutaneous plane
involves mobilization of the stoma and fi xation of the prosthesis to the external oblique, after threading the stoma
through a window in the prosthesis. The advantage of subcutaneous placement is that a laparotomy may not be required.
The disadvantage of this and other local techniques is the
risk of contamination if the stoma has to be sealed and repositioned. No matter how the stoma is sealed, there is a risk of
contamination and of subsequent sepsis. If a septic complication occurs, troublesome sinuses may follow and warrant
removal of the mesh. However, modern polypropylene mesh