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288 Rubin
repair. Cheung et al. [40] reported on a large group with sigmoid colosto-
mies who presented to a stoma clinic. Of these, 127 had a paracolostomy
hernia and 41 (32%) required repair. There is some evidence that the neces-
sity for repair is greater when the hernia is associated with an ileostomy.
Williams et al. [34] found that 9 of 13 (69%) paraileostomy hernias had
needed repair when he examined a group of long-term survivors. On Flesh-
man and Lewis’s questionnaire evaluation [35], 50% of patients with a
paraileostomy hernia reported that they required repair, although some may
have had other reasons for revision besides hernia. The liquid, somewhat
caustic effluent may make a paraileostomy hernia more difficult to manage
nonoperatively. For similar reasons, paraurostomy hernias also seem to re-
quire repair frequently. Schmidt et al. [9] reported that 6 of 8 of their series
underwent repair, as did all 18 in a series by Marshall et al. [14] Unfortu-
nately, both of these chart review studies and the paracolostomy hernia
series reported by Cheung et al. suffer from identifying only patients who
returned for examination because of particularly symptomatic hernias. By
underestimating the total number of hernias, such studies may exaggerate
the frequency with which repair is required. Nonetheless, it is probable that
paraileostomy and paraurostomy hernias are more likely to require repair
than paracolostomy hernias.
OPERATIVE REPAIR
The patient who fails nonoperative management or has an absolute indica-
tion for repair has several options. They include simple local repair, reloca-
tion of the stoma, and local repair with prosthetic material. This last class of
repairs may be accomplished by either an open or a laparascopic approach.
Preparation for surgery requires thoughtful evaluation of the need for repair
and identification of comorbid disease, such as recurrent malignancy or
inflammatory bowel disease. Potential risk factors for recurrence, such as
obesity and pulmonary or urinary dysfunction, should be treated preopera-
tively whenever possible. The surgeon must consider factors such as hernia
size, stoma location, and sites of associated scars that might influence repair
type. In the perioperative period, a standard mechanical and antibiotic
bowel preparation is used for paracolostomy repair. Ileostomy patients are
restricted to clear liquids. If prosthetic mesh will be used, both systemic
and intraluminal antibiotics should be given. Otherwise, management is
similar to that for any clean-contaminated operation.
Techniques of Repair
Local repair, as described by Thorlakson [49], is the oldest and, until re-
cently, had been the most widely practiced form of repair. Thorlakson’s
Parastomal Hernias 289
technique involved making a semicircular or L-shaped skin incision just
outside the ostomy management system zone, exposing and reducing the
sac, and clearing the anterior fascia for several centimeters around the
stoma and the fascial defect. Interrupted nonabsorbable sutures were used
to “snug” the fascia and close the defect around the stoma. Other authors
describe similar repairs using the original laparotomy incision and develop-
ing and extraperitoneal flap to expose the parastomal fascia or incising at
the mucotaneous junction, performing the repair, and rematuring the stoma.
Local repair may also be effected by formal laparotomy, with mass closure
of the defect from within. A novel local approach reported by Bewes [50]
utilizes a musculofascial rotation flap to accomplish repair.
Most authors consider relocation of the stoma to be superior to local
repair. Relocation usually requires laparotomy, lysis of adhesions, and fash-
ioning a new stoma. Consequently morbidity is higher. The enterostomal
therapist plays an important role in preoperative planning and the choice of
alternative stoma sites. The patient is fitted with a sham ostomy manage-
ment system at several potential sites and is observed in supine, sitting,
standing, and various activity-related positions. The best and second-best
alternative sites are determined and marked. There are six generally accept-
able stoma sites [51] (Fig. 5). In any given patient, the number of sites
available may be significantly fewer. Body habitus may be a restricting
factor (obese patients may have difficulty seeing a stoma located at any of
the three lower sites), as may surgical scars and regions of denervation
(proximity to them is believed to predispose to recurrence) [52].
Figure 5 Acceptable abdominal stoma sites.
290 Rubin
There are two techniques of stoma relocation. The classic resiting op-
eration is nicely described by Devlin [30]. A circumstomal incision is made
and the stoma is mobilized and closed. If the hernia is very large, the inci-
sion can be extended and used for laparotomy, but most often the previous
laparotomy incision is reopened. Reduction of the hernia and completion
of the takedown of the stoma are accomplished through simultaneous intra-
peritoneal and extraperitoneal dissections. The new stoma site is created
and the stomal intestine is delivered. The laparotomy incision is closed and
the old hernia is repaired with or without prosthetic material. After these
incisions have been closed and draped outside the field, the new stoma is
matured. If prosthetic material is used or if there is a large subcutaneous
space, closed drainage is used. In 1967, Turnbull and Weakley [53] de-
scribed a technique of relocating ileostomies without laparotomy. Subse-
quently, Taylor et al. [54], Kaufman [55], and Botet et al. [56] used this
approach successfully to relocate a total of 35 stomas. This approach avoids
the morbidity of formal laparotomy, which has been reported to be substan-
tial [47]. Although several surgeons have performed the operation safely,
experience with this technique is limited and there are concerns about po-
tential difficulties arising from the blind nature of the procedure. The in-
ability to lyse adhesions safely, to ensure that no twisting has occurred, and
to mobilize and assess the prestomal bowel make this operation potentially
risky.
The third general type of repair is local repair with prosthetic material.
The development of well-tolerated synthetic mesh and its successful use in
ingunial, ventral, and incisional hernia repair have fostered an increasing
interest in this form of herniorraphy. Most such repairs avoid laparotomy
and the need to fashion a new stoma. The recurrence rate is lower because
repair with mesh circumvents reliance on the weakened musculofascial tis-
sue in the region of the stoma. Many authors have described their favored
technique of prosthetic local repair [30,42,45,46,57–65], utilizing a variety
of approaches. Circumstomal, parastomal, and standard laparotomy inci-
sions have been used. Mesh has been placed in the extraparietal, retromus-
cular, properitoneal, or intraperitoneal plane, and bowel has been brought
out through the center of the mesh or beside it. Most recently, laparascopic
variants of this repair type have been described [66–69].
In 1977, Rosin et al. [45] first described prosthetic local repair. Their
method uses a large elliptical incision to dissect out the prestomal intestine,
the hernial sac, and a rim of good fascia around the hernia. The sac is
opened, its contents are reduced, and the peritoneum and fascia are closed
in layers around the exiting bowel. A piece of polypropylene mesh with a
central orifice sized to fit snugly around the prestomal intestine is passed
over the stoma and sutured to the fascia with interrupted nonabsorbable
sutures. The subcutaneous tissues are irrigated and drained with closed suc-
tion. The skin defect is closed linearly, the former stoma is excised, and a
Parastomal Hernias 291
new stoma is primarily matured in the center of the incision. Although their
results were excellent, the technique has some theoretical drawbacks. Hav-
ing the mesh in the same field with the stoma and leaving the matured
stoma in the incision may increase the chances of infectious complications.
The proximity of the incision to the stoma also may interfere with the fit
of the ostomy management system.
Four years later, Leslie [59] described a method that addresses such
concerns (Figs. 6 and 7). An L-shaped incision is made outside the zone of
the ostomy device. Whenever feasible, the previous incision is used as one
limb of the L. The subcutaneous tissue is raised from the anterior rectus
sheath as a flap until strong fascia is reached at the edges of the hernial
defect. The stoma is not disturbed. The hernia is reduced and, if possible,
the fascia is repaired around the stoma with nonabsorbable sutures. A
square sheet of prosthetic mesh is then partially cut as a keyhole, passed
around the bowel, and sutured atop the anterior sheath with nonabsorbable
material. The split portion is overlapped, producing the correct degree of
snugness, Leslie allows the redundant mesh to fold up along the bowel to
reinforce the repair and prevent future prolapse and retraction. The flap is
closed over a drain, and the ostomy management system is replaced.
Although this is essentially the repair I have used most commonly, I
have found several minor modifications be helpful. I drape the stoma from
the surgical field to minimize the chance of contaminating the prosthetic
material and intubate the stoma with a large Foley catheter to assist in the
often complex task of delineating the prestomal bowel from any herniated
Figure 6 L-shaped incision outside ostomy management system zone for extra-
fascial mesh repair.
292 Rubin
Figure 7 Extrafascial mesh repair showing mesh sutured in place around stoma.
Note collar sutured to stoma and concentric placement of anchoring sutures (inset).
(Modified from Ref. 59.)
loops. Usually polypropylene mesh is used, but the softer, more flexible
polytetrafluoroethylene (PTFE) mesh may also be employed successfully.
The mesh is affixed to the fascia with two concentric rows of interrupted
nonabsorbable sutures, one near the outer edge of the mesh and one close
to the reapproximated trephine to prevent lifting and subprosthetic insinua-
tion of a hernia. Sutures are placed at 2-cm intervals, starting opposite the
split side of the mesh and working toward the split around both sides of
the stoma. In this way the snugness of the repair can be adjusted gradually
by increasing or decreasing the degree of overlap at the split in the mesh.
A finger adjacent to the stoma may help in evaluating the size of the open-
ing. Finally, interrupted 3–0 silk seromuscular sutures (carefully avoiding
the mucosa) are used to attach the mesh to the prestomal bowel. This at-
tachment may prevent insinuation of a small hernial sac inside the mesh
repair as well as motion of the mesh against the bowel, which might lead
to perforation. Adverse consequences due to the proximity of the mesh to
the bowel have been rare. Recently, Moisidis et al. [65] have suggested that
the rate of recurrent herniation following repair with prosthetic mesh cut to
encircle a stoma might be reduced by reinforcing the cut circular margin.
Parastomal Hernias 293
Their tests applied forces simulating those acting on the parastomal abdom-
inal wall to polypropylene mesh with a circular opening cut in it. Signifi-
cant enlargement of the orifice resulted. Reinforcement with a polypropyl-
ene suture placed as a purse string about the cut circular margin markedly
reduced this dilation. Although there is no published clinical experience
with this technique, it is simple, readily available, and unlikely to be associ-
ated with complications in excess of those associated with the use of unre-
inforced mesh.
Another useful prosthetic repair, described by Sugarbaker [60], is of
particular value in patients with large hernias and those whose anterior fas-
cia is too attenuated for use even in a mesh repair (Figs. 8 and 9). In this
method the old laparotomy incision is reopened after intubating and draping
the stoma. The hernia is reduced from within the peritoneal cavity and a
sheet of prosthetic material is sutured in place to close the defect from the
peritoneal side. All sutures are placed with deep bites through the mesh,
peritoneum, and posterior fascial sheath, at close intervals. The mesh is
fixed circumferentially, overlapping the fascial ring except laterally, where
the intestine is made to exit the peritoneal cavity, curving medially atop the
mesh to become the stoma. Sugarbaker believes that his excellent long-
term results have derived in part from the oblique egress of the prestomal
bowel (essentially creating an extraperitoneal stoma). Increased intra-
abdominal pressure is exerted on the mesh rather than on the fascial open-
ing. An alternative form of this intraperitoneal technique uses split mesh
fixed circumferentially around the bowel. Intraperitoneal mesh is particu-
Figure 8 A. Intraperitoneal mesh repair showing mesh in place and bowel enter-
ing from lateral edge. B. Note that bowel is also anchored to lateral abdominal
wall peritoneum. (Modified from Ref. 60.)
294 Rubin
Figure 9 A. Intraperitoneal mesh repair with detail of bowel entering tunnel
above mesh. B. Cross-sectional view corresponding to a-b in A.
larly useful in a recurrent hernia in which there is a marked fascial defect
or in which extraperitoneal mesh has been used previously. Devlin [30] has
described a variant in which the mesh is placed in the properitoneal plane,
theoretically avoiding a difficult intraperitoneal dissection.
Laparascopic parastomal hernia repair was first reported by Porcheron
et al. [66] in 1998. Three subsequent reports have also been published. The
goal of the approach is to provide the benefits of minimally invasive sur-
gery (less pain, shorter hospital stay), to achieve repair results that are at
least equivalent to open repair and to avoid the wound problems (infection,
incisional hernia, recurrence) that can complicate these operations. The
technique involves placement of a 10–12-mm Hasson trocar under direct
vision in the quadrant farthest from the stoma. Two or three additional
trocars are inserted to either side of the first, forming a triangle or semicir-
cle whose apex, the Hasson trocar, is furthest from the stoma. One trocar
should be large enough to accept a clip-application device. Adhesions are
lysed and the hernia contents reduced. The sac need not be excised. A large
sheet of mesh is then inserted and placed, covering the peritoneal surface
of the hernial defect with several centimeters of overlap. Mesh may be
applied uncut (as described by Sugarbaker) or cut to encircle the stoma. A
tacking instrument may be used to fix the mesh in place or percutaneous
tacking sutures may be placed through cutaneous counterincisions. Syn-
Parastomal Hernias 295
chronous abdominal wall hernias may be repaired simultaneously by using
a larger section of mesh or adding additional mesh.
Certain principles are applicable to all types of mesh repair. Periopera-
tive antibiotics should be used. All incisions should be made outside the
zone of the ostomy management system. Whenever possible, the stoma
should be draped outside the operative field. The fascial defect beneath the
mesh may be sutured, but this step is not essential. The mesh must be
attached securely to strong fascia at least 3 cm from the hernia defect.
Finally, when mesh is placed subcutaneously, the space should be drained
by closed suction. While local complications specifically related to the use
of prosthetic material have been surprisingly uncommon, the use of intra-
peritoneal mesh is known to incite adhesion formation. Most authors have
favored polypropylene mesh to repair parastomal hernias. This material has
excellent incorporation characteristics but a high rate of adhesion to bowel.
Greenwalt et al. [70] have recently reported their experience with a com-
posite mesh (polypropylene coated on one side with chemically modified
sodium hyaluronate and carboxymethylcellulose), which reduced such ad-
hesions when it was used to repair simulated hernias in animals. Such a
composite, once studied clinically, may prove to be ideal when an intraperi-
toneal mesh repair is selected.
Results
The technique of local repair has been described largely for historical inter-
est because most results with this method have been very poor. Table 4
lists articles reporting follow-up of parastomal hernia repairs. Local repair
has resulted in recurrence in 64% of cases [14,15,38,40,47,68,73–75,77].
This technique has had a poor record is despite the fact that it was used, in
most series, only on small hernias.
Many experienced authors believe relocation of the stoma to be the
best method of repair for parastomal hernia [1,30,71]. Some consider resit-
ing to be the only choice for large or recurrent hernias. The combined re-
sults of the 16 series in which this technique was used reflect a success rate
of 70% [14,15,26,34,38,40,47,54–56,64,73,75–78]. Several of these au-
thors have noted that they reserved this technique for the most difficult
hernias. When relocation is performed, recurrence has been lower with re-
siting to the contralateral side of the abdomen or the umbilicus rather than
medial to or above the original stoma site [75]. The reported results of
prosthetic local repair are probably better than those with stoma relocation.
A tally of the published outcomes with this technique indicates a success
rate of approximately 88% [34,40,42,45,47,57,58,62,63,71,72,74–77,79–
84]. Infections and other complications have been uncommon. Of 133 mesh
repairs in 22 published series, just 11 infectious complications have been
reported. In only one case did the mesh erode into the bowel, and only 4
296 Rubin
Table 4 Published Results of Parastomal Hernia Repair
Local Relocation Prosthetic Laparoscopic
Years of repair: of stoma: repair: repair:
Authors Year follow-up
2
success/total success/total success/total success/total
Marshall [14] 1975 2.4 4/7 7/9
Prian et al. [15] 1975 2.8 0/3 6/6
Rosin and Benardi [45] 1977 0–4 7/7
Taylor et al. [54] 1978 — 2/2
Abdu [57] 1982 6.2 4/4
Hopkins and Trento [58] 1982 — 1/1
Kaufman [55] 1983 — 4/4
Leslie [71] 1984 4.3 2/2
Sugarbaker [72] 1985 5.1 7/7
von Smitten et al. [26] 1986 — 2/2
Horgan and Hughes [73] 1986 0.8–5 0/2 1/1
Bayer [74] 1986 0–4 6/7
Allen-Mersh and Thompson [75] 1988 3–33 17/32 11/21 0/1
Williams et al. [34] 1990 — 0/2 3/9 1/1
deRuiter and Bijnen [42] 1992 1.5 13/14
Byers et al. [76] 1992 1.2 5/10 9/9
Parastomal Hernias 297
Alexandre and Bouillot [77] 1993 3 0/2 4/5 10/11
Rubin et al. [47] 1994 206 7/36 14 /25 4/7
Carlsen and Bergan [38] 1995 2.7 4/10 4/5
Stephenson and Phillips
[64] 1995 0.8 8/8
Botet et al. [56] 1996 0–3 11/11
Helal et al. [78] 1997 1.9 17/19
Morris-Stiff and Hughes [62] 1998 6.8 5/7
Hofstetter et al. [79] 1998 — 13/13
Porcheron et al. [66] 1998 1 1/1
Bickel et al. [67] 1999 1 1/1
Stelzner et al. [80] 1999 2.5 8/9
Tekkis et al. [81] 1999 2 5/5
Kasperk et al. [63] 2000 0.3–3 5/7
Voitk [68] 2000 0.7 4/4
Aldridge and Simpson [82] 2001 0.8 0/1 0/1
Cheung et al. [40] 2001 3.1 7/13 15/25 0/2
Amin et al. [83] 2001 0.5 9/9
Franks and Hrebinko [84] 2001 2.2 6/6
Kozlowski et al. [69] 2001 0–2.8 4/4
Total 39/108 114/162 115/130 10/10
a
Single numbers indicate mean follow-up; hyphenated numbers indicate range.