Parastomal Hernia - Symptoms, Diagnosis, and Treatment

What Is Parastomal Hernia?

A parastomal hernia is a form of incisional hernia in which abdominal contents protrude through flaws in the abdominal wall near the stoma site. Typically, this occurs gradually, and the hernia may expand over time.

First, it is crucial to remember that hernias are extremely common. Up to 70 percent of ostomates (one who undergoes ostomy surgery) would get one. When the stoma’s margins detach from the muscle, hernias may appear. When a muscle incision is made while creating a stoma, weakness may be caused, resulting in a hernia.

What Is a Stoma?

A stoma is an opening created on the abdomen for emptying stool or urine from the body.

What Are the Symptoms of a Parastomal Hernia?

They grow gradually, and the most commonly noticed symptoms are:

• Severe pain and skin irritation are noticed around the stoma.

• Protrusion of the stoma beyond the abdominal wall.

What Are the Risk Factors for Developing a Parastomal Hernia?

Few patients are more prone to get a parastomal hernia. They are:

• Older people above the age of 60.

• Female gender.

• Obesity.

• Patients with underlying medical conditions like hypertension and diabetes.

• Smokers.

• Patients under steroid therapy.

• Respiratory diseases like chronic obstructive pulmonary disease.

• Conditions that increase abdominal pressure (e.g., ascites).

How Is a Parastomal Hernia Diagnosed?

There is no diagnostic gold standard available. The diagnostic modalities used are clinical history, physical examination, and imaging studies.

• A clinical history of pain, protrusion, and bowel obstruction.

• Physical examination of the bulge around the stoma is done with the patient breathing strongly through their mouth with the nose tightly closed. The strain caused by this method makes the bulge prominent for proper examination. The diagnosis is even more difficult for those with severe pain and obesity.

• Imaging studies like computed tomography and ultrasonography are more successful in detecting hernias.

What Is the Treatment for Parastomal Hernia?

The treatment can be non-surgical or surgical. The decision on the type of management option depends on the patient’s condition.

The Indications for Non-surgical Repair Include the Following:

• Aesthetic concerns.

• Mild pain.

• The bulge around the stoma.

• Poor appliance fit or leakage.

The patients with the above factors are not candidates for immediate surgical intervention. A hernia belt is used to reduce the pain in these patients.

The Indications for Definite Surgical Repair Include the Following:

• When there is an obstruction that is difficult to be managed conservatively.

• Strangulation leads to severe pain and bulging at the site of the hernia.

Those with underlying severe medical conditions and end-stage and metastatic cancer are contraindicated for surgical repair.

The Surgical Intervention Can Be:

• Primary suture repair.

• Re-siting of the stoma.

• Using a prosthetic mesh for repair.

The Types of Surgical Repair Include:

1. Primary Suture Repair:

• One of the oldest methods of repair.

• Here, an incision is made with a blade, and the hernia sac is excised or reduced.

• The open area is approximated with healthy muscles and tissues and closed with sutures.

• Primary suture repair is done only for emergency cases and critically ill patients whose survival is questionable with other surgical interventions.

2. Stoma Relocation:

• The old stoma can be relocated to a new site when the management of the old site is poor.

• To prevent hernia recurrence, the new and the old stoma site is closed with a mesh.

3. Mesh-Based Repair:

The most acceptable method of hernia repair is by using mesh. The recurrence rate associated with this technique is also low. The mesh-based repairs vary according to type, location, and surgical technique.

A. According to type, there are two types:

Synthetic Mesh:

• Synthetic mesh can be macroporous or microporous.

• The macroporous type consists of polypropylene or polyester. It has good strength and causes tissue ingrowth.

• The microporous type consists of expanded polytetrafluoroethylene, which does not cause tissue ingrowth.

• A composite type combining both macroporous and microporous types is also available.

• They are used on a clean site.

• The disadvantage of synthetic mesh is infection and mesh contraction over time.

Biologic Mesh:

• More vascularized and resistant to infection.

• Expensive compared to synthetic mesh.

• Used in the repair of the contaminated site.

B. According to the location of the mesh placement, there are onlay, sublay, and underlay.

• Onlay mesh is placed on the abdominal wall muscles (anterior rectus sheath and external oblique aponeurosis) through an incision near the hernia.

• It is a simple and fast procedure. However, the infection and the recurrence rate are high.

• The sublay or retro muscular type is placed between the rectus muscle abdominus and posterior rectus sheath.

• This type is technique sensitive but poses less risk than the onlay type.

• The underlay-type mesh is placed within the abdomen in the preperitoneal or intraperitoneal layer.

• This type is also technique-sensitive.

• Has the lowest recurrence rate.

C. The Sugarbaker and the keyhole technique are available according to the type of surgical repair. Both these techniques provide an excellent parastomal hernia repair with minimal risk of complications.

• The Sugarbaker procedure entails narrowing the hernia sac inside the peritoneal cavity and inserting the mesh well within the defect.

• A small gap is left near the stoma exit by lateralizing the bowel to make the intestine pass through the mesh.

• The bowel is constructed to pass into the middle of the mesh in the keyhole technique.

Another technique that is a modification of the Sugarbaker technique is by using laparoscopy. The laparoscopic method produces less pain, faster recovery after the surgery, and better aesthetics.

What Are the Outcomes of Parastomal Hernia Repair?

The outcome of parastomal hernia repair is not satisfactory. With the primary suture repair technique, the recurrence is nine times that of mesh repair. Infection rates were less postoperatively with mesh repair. The latest technique of laparoscopic repair is advantageous. Laparoscopy avoids the need for large incisions, makes it easy to visualize the defect, and provides better closure and a faster recovery.

How to Avoid a Parastomal Hernia?

Parastomal hernia can be prevented by various means. After surgery, give the body time to heal and start exercising. Wearing supportive garments and strengthening the abdominal wall through core muscle exercises reduces the risk of hernia formation and provides comfort when a hernia already exists.

Conclusion

Parastomal hernia is a complicated condition that is repaired to prevent further complications. Prosthetic mesh is the standard technique to repair the defect with less recurrence. The search for an ideal mesh with less infectivity, less recurrence, and promoting tissue ingrowth is still under study. Further research is going on to invent a standard gold treatment.