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298 Rubin
patients have required removal of their mesh. Other reported complications
directly attributable to the mesh include intestinal obstruction in 3 patients
and mesh migration in two.
Both stoma relocation and prosthetic repair may be associated with
significant morbidity and complications. In one published series, stoma re-
location was associated with a 44% recurrence rate, and an additional 24%
of these patients developed an incisional hernia. When a prosthetic repair
was used, the recurrence rate was 43%, and 29% of patients required treat-
ment for a postoperative parastomal infection [47].
Laparascopic repair of parastomal hernias represents a new approach
that may address the problems of incision and wound-related complications.
It has a very limited track record, but early results are promising. One area
of concern is the apparent difficulty of performing the procedure. Operative
times have ranged from 47 min to 5
1
⁄
2
hr. Excellent results with similar
techniques in the management of difficult incisional hernias suggest that
this method has the potential to become the repair of choice [85,86].
Selection of Repair Type
Once the indication for operative repair has been established, the surgeon
must decide which type of hernia repair is most appropriate. This decision
must be individualized. As a rule, simple local repair should be avoided.
The choice between local prosthetic repair, stoma relocation, and laparas-
copic repair depends on the condition of the stoma and abdomen locally,
the general condition of the patient, and, ultimately, the surgeon’s prefer-
ence. Both Goligher [1] and Corman [46] consider resiting preferable, al-
though Goligher’s data antedate much of the recent literature on mesh re-
pairs. Table 3 suggests that the efficacy of prosthetic repair is probably
superior. My approach is to use whichever type of repair seems most suit-
able for the particular patient. If a stoma is poorly situated, it should be
resited if possible. For example, a hernia at a stoma that is not transrectus
or is out of view in an obese patient should be resited. On the other hand,
a mesh repair may be chosen for a patient who likes the current site and has
had no management difficulties. In a patient with severe comorbid disease,
performing an extraperitoneal mesh repair or a translocation without lapa-
rotomy may avoid the complications associated with a major abdominal
operation. In younger patients, local prosthetic repair should be considered
first, saving relocation to alternate stoma sites for further recurrences. A
patient with multiple scars at the other potential stoma sites may also be
best treated with a local mesh repair. Stomas may be placed in previous
incision sites, but this is likely to increase recurrence rate and difficulty
with the fit of the ostomy management system. As experience with laparas-
copic repair techniques increases, such procedures may be undertaken with
greater confidence.
Parastomal Hernias 299
Postoperative Management and Complications
Except the fact that these patients must avoid heavy lifting and vigorous
activity for at least 2 months, their postoperative management is the same
as that of any patient with a new stoma. Winkler [27] believes that use of
a corset or binder is essential in the short- and long-term management of
these patients, but there is little evidence at this time to justify this recom-
mendation.
Serious complications other than recurrence are uncommon with para-
stomal hernia repair. Seroma occurs to some degree in almost all patients.
Most seromas should be treated expectantly, although aspiration may be
indicated for those who are significantly symptomatic. To prevent contami-
nation, aspiration should be avoided, if possible, when prosthetic material
has been used. Infectious wound complications are unusual; when present,
they are usually minor. Few such complications are noted in the literature.
Even when mesh is used, local infection occurs in fewer than 10% of pa-
tients and is serious in fewer than 5%. Other mesh-related complications
such as erosion, migration, and intestinal obstruction are very uncommon.
Recurrence is a significant problem, however, occurring after over 70% of
local repairs, almost 30% of relocation repairs, and approximately 10% of
prosthetic repairs. Incisional hernia is also not unusual after parastomal her-
nia repair. When relocation is performed, concern for infection often pre-
cludes using mesh to repair the previous (enlarged) stoma site. The inci-
sional hernia rate following these operations may exceed 50% [47]. Finally,
there is always the risk that manipulating, moving, or dissecting near the
stoma will cause a complication, such as an injury to the bowel or its blood
supply, that will have adverse consequences in the early or late postopera-
tive period.
PREVENTION
It is undeniable that parastomal hernia is a common problem in individuals
with an ostomy and that it may cause serious complications or management
problems. Repair, when required, may be difficult, and the condition is
prone to recurrence. As with many other surgical complications, prevention
is the most efficacious way to deal with the problem. Goligher [1] says that
he knows of no certain preventive of this complication, but that by adhering
to a few principles, the risk of herniation can be minimized.
Preoperatively all possible efforts should be made to improve the risk
factors for hernia. Preoperative planning and marking of the stoma site are
essential and have been covered in detail in Chapter 3 on preoperative con-
siderations. Meticulous attention must be paid to the construction of the
initial stoma, as described in the chapters on the end sigmoid colostomy
300 Rubin
(Chapter 6) and the end ileostomy (Chapter 9). The choice of incision is
important. While there is no published work suggesting that proximity of
the laparotomy incision to the trephine increases the risk of hernia, conflu-
ence of a parastomal hernia with a midline incisional hernia is not an un-
usual occurrence. It may be reasonable to choose a contralateral paramedian
incision to diminish hernia risk. Many colorectal surgeons prefer a midline
approach, as a paramedian scar may preclude using that side of the abdo-
men for future stomas. A right-sided paramedian incision should certainly
be avoided in a patient with inflammatory bowel disease. In locating the
stoma, a transrectus construction is superior to a lateral one. An umbilical
stoma will also have a lower rate of hernia formation [18]. When possible,
the creation of an extraperitoneal stoma probably also reduces the risk of
herniation. The size of the trephine should only be large enough to admit
the bowel itself. Resnick [87] has devised a device that controls the size of
the fascial aperture. He believes that it reduces the risk of hernia develop-
ment. An interesting report by Bayer et al. [74] investigated the benefit and
risks of placing a ring of polypropylene mesh around all colostomies to
prevent hernia (Fig. 10). A total of 43 patients were followed for up to 4
years. None developed a hernia and only 7 had complications attributable
to the mesh. Light [88] has championed a similar technique. These results
are intriguing, but a randomized prospective study of this method against
Figure 10 Paracolostomy mesh reinforcement showing collar mesh (inset)
around stoma and anchored to anterior fascia. (Modified from Ref. 74.)
Parastomal Hernias 301
conventional technique should be completed before considering its adoption
for routine use. Inserting prophylactic mesh in high-risk patients, however,
may be an appropriate measure.
The surgeon must remember that, for the long-term survivor, the sin-
gle most important part of the operation is the creation of the stoma. Even
minor malfunction of the stoma may seriously hamper the patient’s daily
activities and quality of life. The construction of the stoma should be metic-
ulous, and it should be performed by an experienced attending surgeon or
done under the guidance of such an individual.
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16
Stomal Prolapse
Seth Rosen and Juan J. Nogueras
Cleveland Clinic Florida, Weston, Florida, U.S.A.
INTRODUCTION
Many issues confront patients with a newly formed stoma. These issues
include the need to meet the physical and psychological challenges unique
to their new body architecture. Any complications in stoma management
can hinder patient acceptance. The ideal stoma combines optimal functional
and cosmetic results in the eyes of both the patient and surgeon. Stoma
prolapse, a condition in which the full thickness of the intestine protrudes
through the stoma, is one of the most common complications (Fig. 1). Pro-
lapse occurs in both end and loop stomas, ileostomies and colostomies, as
well as urostomies and continent ileostomies. This chapter reviews the cur-
rent literature on stomal prolapse, specifically addressing etiology, risk fac-
tors, and technical considerations in preventing and treating prolapse.
INCIDENCE
The incidence of stomal prolapse is variable, depending on the type of
stoma and its location, age of patient, primary diagnosis, and length of
follow-up. Fleshman and Lewis [1] reported the incidence of stoma- related
complications based on a review of 16,740 entries in the United Ostomy
Association Registry. The incidence of prolapse for ileostomy, colostomy,
and urostomy was 3, 2, and <1%, respectively. Other published data have
often revealed far less optimistic numbers (Table 1).
In a comprehensive analysis of 1616 enteric stomas created at Cook
County Hospital over a 20-year period, Park and colleagues [9] found an
overall 2% incidence of prolapse. A multivariate analysis revealed that only
advanced age and lack of preoperative marking by an enterostomal therapist
were significant risk factors for the development of long-term complica-
tions, including prolapse.
307