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278 Rubin
Table 1 Published Series of Incidence of Parastomal Hernia
Incidence in
Years of >30-day Required
Authors Year Stoma type Number follow-up* survivors operation Comment
Birnbaum and Ferrier [2] 1952 End colostomy 569 1–34 27/569 (5%) —
b,d
Grier et al. [3] 1964 End colostomy 50 5.2 29/50 (58%) —
c,e,f
Green [4] 1966 Loop colostomy 160 2–7 8/318 (3%) —
b,d,g
End colostomy
Watts et al. [5] 1966 End ileostomy 151 3.4 3/119 (3%) 0/3
b
Roy et al. [6] 1970 End ileostomy 497 7.4 3/469 (1%) —
b,h
Burns [7] 1970 Loop colostomy 99 0– 21 1/99 (1%) 6/16
b
End colostomy 219 15/219 (7%)
Harbach et al. [8] 1971 Urostomy 244 3–15 12/214 (6%) —
b
Schmidt et al. [9] 1973 Urostomy 178 3–11 8/172 (5%) 6/8
b,i
Saha et al. [10] 1973 Loop colostomy 190 1–7 2/200 (1%) —
b,d
End colostomy 10
Balslev [11] 1973 End colostomy 546 14.5 62/110 (56%) 9/62
c,e
Kronborg et al. [12] 1974 End colostomy 362 1–10 42/362 (12%) 4/42
b,d
Harshaw et al. [13] 1974 End colostomy 99 1 –8 9/99 (9%) —
b,d
Marshall et al. [14] 1975 Urostomy 400 2–10 18/400 (5%) —
b,d,h
Prian et al. [15] 1975 Colostomy 262 0–20 8/262 (3%) —
b,d,h
Marks and Ritchie [16] 1975 End colostomy 227 0–6 23/224 (10%) —
b,j
Whittaker and Goligher 1975 End colostomy 251 7–20 36/251 (14%) —
b,e
[17]
Parastomal Hernias 279
Raza et al. [18] 1977 End umbilical colostomy 101 2.5 0/101 (0%) —
b
Abrams et al. [19] 1979 Loop transverse colostomy 202 9–18 4/189 —
b
End sigmoid colostomy 46
Wara et al. [20] 1981 Loop transverse colostomy 257 0–10 10/212 (5%) —
b,k
Stothert et al. [21] 1982 Ileostomy 10 0–5 2/42 (5%) —
b,l
Transverse colostomy 23
Sigmoid colostomy 18
Eldrup et al. [22] 1981 Transrectus colostomy 77 2.8 1/77 (1%) —
b,e
Lateral colostomy 63 12/63 (19%)
Burgess et al. [23] 1984 End colostomy 124 0 –10 6/121 (5%) 1/6
b
Phillips et al. [24] 1985 Colostomy 328 1–4 11/243 (5%) —
b,e,m,n
8/175 (4%) —
Ileostomy 232
Pearl et al. [25] 1985 All stomas 610 — 5/610 (1%) —
b,o
von Smitten et al. [26] 1986 End colostomy 54 1–8 26/54 (48%) 2/26 (8%)
c,e
Winkler [27] 1986 All stomas 164 — 42/164 (30%) —
c,g,p,q
Carlstedt et al. [28] 1987 End ileostomy 203 8 3/203 (1%) 3/3 (100%)
e
Sjodhal et al. [29] 1988 End colostomy 79 7 7/79 (9%) 4/9
h,e,r
End ileostomy 45 1/45 (2%) —
Devlin [30] 1988 Ileostomy 102 — 5/102 —
t
Porter et al. [31] 1989 End colostomy 130 2.9 14/130 (11%) 5/14 (36%)
b
Leenan and Kuypers [32] 1989 Colostomy 184 — 20/184 (11%) —
b,s
Ileostomy 153 3/153 (2%)
Phillips et al. [33] 1989 End ileostomy 70 6 3/70 (4%) —
b,g
Williams et al. [34] 1990 End ileostomy 60 6.5 13/46 (28%) 9/13
c,e
280 Rubin
Table 1 Continued
Incidence in
Years of >30-day Required
Authors Year Stoma type Number follow-up* survivors operation Comment
Fleshman and Lewis [35] 1991 Ileostomy 6024 — 4% 50%
a
Colostomy 7083 11%
Urostomy 2613 8%
Oritz et al. [36] 1994 End sigmoid colostomy 54 5 26/54 (48%) —
c,e
Londono-Schimmer et al. 1994 End colostomy 203 5.5 43/203 (21.2%) 10/43 (23%)
e,v
[37]
Carlsen and Bergan [38] 1995 End ileostomy 358 2.7 8/358 (2%) 8/8 (100%)
t
Cheung [39] 1995 Colostomy 189 3.2 66/189 (35%) —
b,e,v,w
Urostomy 123 34/123 (28%)
Ileostomy 10 0/10 (0%)
Cheung et al. [40] 2001 Sigmoid colostomy 322 — 127/322 (39%) 41/127 (32%)
b,e,w,x,y
*Single numbers indicate mean follow-up; hyphenated numbers indicate range.
a
, questionnaire;
b
, chart review;
c
, all patients examined;
d
, fails to exclude early deaths;
e
, survivors only;
f
, nonrandom groups of patients selected by fact
that they did not irrigate colostomy;
g
, 86 patients had stoma closure during study period;
h
, only considers hernias that required repair;
i
, five hernias
occurred within 1 week of operation;
j
, 32% of patients followed >5 years had hernias;
k
, 105 were closed during study period;
l
, both hernias in proximal
colon group;
m
, 141 colostomies were closed during study period;
n
, in group of 100 patients referred for stoma problems, 11 had hernias;
o
, study of early
postoperative complications occurring during the admission at which stoma was created;
p
, rate in outpatient group was 45%;
q
, nonrandom group of patients
presenting for stoma problem;
r
, does not identify which hernia required repair;
s
, results for end, loop; double barreled stomas not distinguished;
t
, methods
of study unknown;
u
, hernias present in 36.7% of patients followed for 10 years;
v
, series includes 26 loop colostomies and 2 loop ileostomies;
w
, nonrandom
group of patients attending a stoma clinic;
x
, may include patients also reported in Cheung’s 1995 series;
y
, includes 20 loop colostomies.
Parastomal Hernias 281
Table 2 Factors Predisposing to Parastomal Hernia
Factors Supporting studies
a
Refuting studies
a
Patient characteristics
Obesity 14 26,32
Advanced age 37 1,27,29
Debility/malnutrition — —
Malignancy — 29,32
Obstructive pulmonary disease — —
Urinary outflow disease — —
Steroid use — —
Factors at operation
Colonic stoma 21,29,35,39 24
Large trephine size — —
Stoma placed in laparotomy incision 1,4 31
Stoma placed lateral to rectus muscle 2,3,22,29 16,26,34,36,37
Transperitioneal technique 13,16,17,37 26,31
Prior denervation/devascularization — —
of site
Laparotomy or other incision nearby — —
Urgent/emergent operation 20,21 31,32
Intestinal distention/edema — —
No intraabdominal fixation of bowel — 26,38
Postoperative factors
Parastomal infection — —
Other abdominal complications 14,16 26
Postoperative distention/ascites — —
Radiation therapy 14 —
Weight gain — 34,37
Development of prolapse — —
Early or excessive exertion — —
Long-term survival 12,16,29,34,37 —
a
Numbers shown for studies refer to references listed at end of chapter.
factors have been studied and found truly instrumental in increasing the
risk. Although many factors—such as obesity, steroid use, advanced age,
and obstructive pulmonary disease—are likely to play a part in hernia for-
mation, the evidence is largely anecdotal. One frequent observation is that
a permanent colostomy develops a hernia (0–58%) more commonly than a
permanent ileostomy or urostomy (0–28%). Goligher et al. [41] have pro-
posed that this may be related to the relatively advanced age and associated
muscle weakness in the colostomate, whereas Winkler [27] has noted the
tendency of solid stool to enlarge the orifice over time. DeRuiter and Bijnen
[42] have offered a compelling explanation of the forces contributing to
parastomal hernia formation. According to the Law of Laplace, there is a
282 Rubin
radial force on the abdominal wall that is related to the pressure in the
abdominal cavity and that cavity’s diameter. Any opening constructed in
the abdominal wall is subject to a tangential force (which would tend to
enlarge it) that is proportional to this radial force and to the radius of the
opening itself. This law of physics elegantly explains an increased hernia
rate with colostomy formation (larger trephine size), emergency operation
(increased abdominal pressure and larger trephine size), and obesity (greater
abdominal diameter).
Improperly located stomas also have a higher incidence of hernia. Go-
ligher [1] and Green [4] discuss at length the many early and late complica-
tions associated with bringing a stoma through the laparotomy incision.
Goligher notes that “the grosser forms [of paracolostomy hernia] are found
in cases where the colon has been brought out in the line of the main
incision.” Several authors have noted that stomas placed through the rectus
muscle have significantly lower incidence of parastomal hernia than those
placed lateral to the rectus muscle. Birnbaum and Ferrier [2], in one of the
largest series in the literature, noted that the incidence was four times
greater in lateral colostomies. Grier et al. [3] examined 50 patients with a
mean time of 5.4 years after colostomy and found hernias associated with
only 1 of 10 (10%) transrectus stomas but with 28 of 40 (70%) of those
placed lateral to the rectus muscle. Eldrup et al. [21] found hernias in 1 and
19% of transrectus and lateral colostomies, respectively, and Sjodahl et
al. [29] noted rates of 3 and 26%. Five other series in which the subject
was investigated, however, failed to show a significant difference [16,26,34,
36,37].
In 1958, Goligher [43] described a technique to create extraperitoneal
stomas. Devlin [30], and Todd [44] do not believe that this practice lessens
the incidence of parastomal hernia. The literature contradicts this impres-
sion. In a series by Harshaw et al. [13], none of 17 extraperitoneal colosto-
mies developed hernias, whereas 9 of 28 (11%) transperitoneal ones did.
In a series of colostomies by Marks et al. [16], the figures were 1 of 37
(3%) and 22 of 190 (12%), respectively. Whittaker et al. [17] found hernias
associated with 8 of 89 (9%) extraperitoneal colostomies and 28 of 162
(17%) transperitoneal colostomies. Finally, Londono-Schimmer et al. [37]
found a tenfold increase in paracolostomy hernias when a transperitoneal
technique was used (3.5 vs. 35%).
Urgent or emergency surgery has been implicated as a risk factor for
hernia. This hypothesis is very difficult to study, because mortality is high
in this group and survivors often have their stoma closed or revised. Wara
et al. [20] nonetheless found, in children, a statistically significant increase
in herniation and prolapse with urgently created stomas. Stothert et al. [21]
also noted a higher rate of hernia in stomas created at emergency surgery.
As already discussed, this may be related to larger stoma apertures required
to accommodate an obstructed colon or to the increased pressures associ-
ated with intra-abdominal catastrophes.
Parastomal Hernias 283
Although many technical factors that predispose to parastomal hernia-
tion have been documented, patient characteristics and postoperative factors
have been less well studied. Many experts cite obesity, advanced age, de-
bility, malignant disease, pulmonary disease, and steroid use as certain
culprits; however, good studies of these factors are lacking. Since these
comorbidities also are associated with a decrease in life expectancy, their
influence on incidence of the hernia may be diminished statistically, since
nonsurvivors are included in most calculations. Similarly, in many series
evaluating the incidence of parastomal hernia, the only factors shown to be
important are the occurrence of a postoperative abdominal complication
(especially wound infection and urinary retention) and the use of postopera-
tive radiation therapy [14,16]. A number of authors have cited anecdotal
experience that parastomal infection and abdominal distention or ascites are
commonly followed by hernia formation.
One finding that has been widely noted is that the likelihood of paras-
tomal hernia development increases over time. Some 23–48% of hernias
appear within 1 year and 36%–100% within 2 years [12,15,16,39,45]. It
has also been reported that loop stomas may have a lower rate of hernia
formation. However, many loop stomas are temporary and are closed in less
than 1 year (before a hernia can develop). Therefore their true incidence of
herniation may be higher.
The many reported series of parastomal hernias suffer largely from
being retrospective chart-review or questionnaire-type evaluations. Dura-
tion and degree of follow-up are variable, different stoma types are grouped
together, and often only large, symptomatic, or operated hernias are noted.
Only Grier et al. [3], Balslev [11], von Smitten et al. [26] and Ortiz et al.
[36] performed physical examination in end colostomy patients with mean
follow-up exceeding 5 years. They found parastomal hernias in 58, 56, 48,
and 48% of their patients, respectively. Williams et al. [34] did the same
for end ileostomy patients. A total of 28% were found to have hernias.
These series most accurately assess the magnitude of the problem.
TYPES OF HERNIA
Four distinct types of hernia or pseudohernia can develop near a stoma.
The most common is the “true parastomal” hernia (Fig. 1), which has a
peritoneal sac emanating from an enlarged fascial opening. The sac may be
found in a subcutaneous or interstitial position. A second type of hernia,
designated “intrastomal” (Fig. 2), occurs when an intraperitoneal structure
protrudes into the space between the serosal surface of a spout ileostomy
or the extension of the peritoneal cavity created whenever stoma prolapse
occurs. The fascial defect is enlarged, if only slightly, and the sac may be
composed only of the visceral peritoneum of the prestomal bowel. Both
variants have been described, but they are rare [30,46]. The third and fourth
284 Rubin
Figure 1 True parastomal hernia.
hernia types are actually pseudohernias, but their symptoms and treatment
may be similar to those of true hernias. Figure 3 depicts “subcutaneous
prolapse.” As with frank prolapse, redundancy and other factors may lead
to advancement of the prestomal intestine from the peritoneal cavity proper.
This results in a subcutaneous redundant loop that creates a bulge when
distended. Identification of this variant is important, because there may be
little or no fascial defect and local revision may suffice (if symptoms war-
rant repair). The final type (Fig. 4) is the classic “pseudohernia.” Seen less
and less frequently because it is peculiar to laterally placed stomas, the pseu-
Figure 2 Intrastomal hernia (may be associated with prolapse).
Parastomal Hernias 285
Figure 3 Subcutaneuous prolapse (pseudohernia) with intact fascial ring.
dohernia is a diffuse bulge without enlarged fascial defect or herniated
structure in the subcutaneous space that develops over time because of rela-
tively weak or denervated muscles lateral to the rectus muscle.
More than 90% of the parastomal hernias seen today are of the true
parastomal variety. The fascial defect is often relatively small although it
can be large, especially when the stoma trephine is close to the fascial
closure of another incision. Small bowel and omentum commonly occupy
the hernial sac, but virtually any intraperitoneal organ may enter it. Parasto-
mal hernias seem to occur most commonly at either the mesenteric aspect
or lateral to the stoma. Knowing the difference between prolapse and herni-
ation is important. Prolapse results largely from intestinal redundancy and
lack of fixation, whereas hernia implies excessive size of the fascial ring.
Figure 4 Pseudohernia due to weakness of abdominal wall without fascial de-
fect.
286 Rubin
Prolonged or repeated prolapse may lead to widening of the trephine and
development of a hernia, and patients with a hernia may coincidentally
develop prolapse.
EVALUATION AND MANAGEMENT OPTIONS
The evaluation of the patient with an ostomy who may have a hernia begins
with a directed history, eliciting the abdominal or stoma-related complaint,
its duration, and its relationship to body positioning and physical activities.
Local pain is common. A bulge may occur with straining, standing, or after
a large meal. Intermittent difficulty with the appliance may also indicate
occult hernia. It is important to inquire about signs and symptoms of intesti-
nal obstruction (which may be very mild) and difficulty with irrigation of
the stoma. Stool size and consistency and presence of prolapse should also
be elicited.
Parastomal hernia may be relatively obvious or extremely difficult to
diagnose. Examination requires that the patient be unclothed with the os-
tomy management system removed. The region of the stoma is examined.
Palpation is done with the patient first recumbent and then standing. The
patient is asked to relax and then to perform a Valsalva maneuver repeat-
edly. Perhaps the most valuable and often omitted technique in the evalua-
tion of patients with stoma problems is digital examination of the stoma
during these maneuvers. Such examination allows palpation of the fascial
aperture and the most direct evaluation of the subcutaneous parastomal re-
gion. The site of the stoma, presence of scars, degree of obesity, evidence
of abdominal muscle denervation, quality of the skin locally, and potential
alternative stomas sites should be noted during the examination.
In the patient whose symptoms suggest parastomal hernia but where
no hernia can be detected, computed tomography (CT) scanning may be of
value. In a population of patients with ileostomy, Williams et al. [34] found
that 20% of parastomal hernias were detectable only by CT. Such detection
allowed two symptomatic patients to undergo repair.
Not all hernias require repair. Central to the decision between opera-
tive and nonoperative treatment is the surgeon’s accurate assessment of the
nature of the hernia, its current or potential seriousness, and how adversely
it affects the patient. The indications and contraindications for repair of
parastomal hernia are listed in Table 3. Most contraindications are relative,
because life-threatening complications require repair in all but the terminal
patient.
Virtually all authors agree that for the ostomy patient with an asymp-
tomatic or mildly symptomatic hernia, nonoperative management should
be attempted. Most hernias are well tolerated. Serious complications are
uncommon, and operative repair may be difficult, produce morbidity, and
Parastomal Hernias 287
Table 3 Indications and Contraindications to Parastomal
Hernia Repair
Indications
Absolute
Incarceration
Strangulation
Obstruction
Fistulization
Perforation (related to incarceration or irrigation)
Stoma ischemia
Relative
History of incarceration
Symptoms suggestive of obstruction
Difficulty maintaining appliance fit
Patient unable to see or manage stoma
Irrigation difficulty
Pain related to hernia
Ulceration of overlying skin
Cosmetic unacceptability
Tight neck of hernia that is difficult to reduce
Concomitant prolapse, stricture, or other indication for revision
Contraindications:
Absolute
End-stage malignancy
Relative
Recurrent, metastatic, or inoperable malignancy
Severe comorbid disease
Temporary stoma
have a significant rate of recurrence. Three authors who investigated the
rate at which parastomal hernia is complicated by incarceration, obstruc-
tion, or strangulation found that such emergencies developed in only 13–
16% of cases [30,39,47]. Nonoperative management centers around the use
of a binder or a belt that incorporates a plastic disk atop the flange of the
ostomy device to maintain the hernia in a reduced state. Such an approach
may allow the symptomatic poor-risk patient to live comfortably with a
hernia.
It has been suggested that only 10–20% of parastomal hernias will
ever require repair [48]. However, this figure may be low. In Balslev’s
study [11], which included meticulous long-term follow-up, 9 of 62 (15%)
patients with hernias required repair. Londono-Schimmer et al. [37], who
followed consecutive patients who had an end colostomy created over a 10-
year period, noted that 10 of 43 (23%) who developed a hernia underwent