A parastomal hernia develops when abdominal contents protrude through a weakened area of the abdominal wall adjacent to a stoma, a surgically created opening on the abdomen that allows waste to exit the body (e.g., an ileostomy or colostomy). The article will explore the process of repairing a parastomal hernia, detailing the considerations for intervention, surgical approaches, recovery expectations, and potential outcomes.
Determining the Need for Repair
Recognizing a parastomal hernia often begins with a visible bulge around the stoma, which may become more prominent when coughing or straining. Patients might also experience discomfort, pain, or difficulty maintaining a proper seal with their ostomy appliance, leading to leakage and skin irritation.
A physical examination is usually the initial step in diagnosis, where a healthcare provider assesses the bulge and tenderness around the stoma. CT scans are frequently used to define the defect and differentiate it from other types of hernias.
Not all parastomal hernias require immediate surgical intervention, especially if small and asymptomatic; a “watchful waiting” approach may be adopted. Non-surgical management includes specialized support belts or garments, which can help support abdominal muscles and potentially prevent worsening. However, surgery is typically considered when the hernia causes persistent pain, interferes with stoma management, or poses a risk of complications like bowel obstruction or strangulation, which are medical emergencies. Surgeons consider hernia size, symptom severity, and overall patient health when recommending repair.
Surgical Repair Techniques
Surgical repair of a parastomal hernia can be approached in several ways, primarily categorized as open or minimally invasive procedures. An open repair involves a larger incision near the stoma, providing the surgeon with a direct view of the hernia defect. Conversely, minimally invasive techniques, such as laparoscopic or robotic surgery, utilize smaller incisions and specialized instruments with a camera, potentially leading to less post-operative pain and faster recovery.
Simple suture repair is generally not preferred for parastomal hernias due to high recurrence rates, sometimes reaching 70 percent. Mesh reinforcement is the standard of care, providing stronger, more durable repair and significantly reducing recurrence rates compared to suture-only methods. Surgical mesh acts as a scaffold to strengthen the abdominal wall where the defect occurred.
Mesh materials broadly fall into two categories: synthetic and biologic. Synthetic mesh, often made from polypropylene, is a permanent material that integrates with the body’s tissues. Biologic mesh, derived from human or animal tissue, is absorbable and sometimes used in specific situations like contaminated fields or high infection risk. However, biologic mesh typically has a higher cost and has shown higher recurrence rates in elective settings compared to synthetic mesh.
Mesh Placement Techniques
The “Sugarbaker” method involves placing the mesh in an overlay fashion, often intraperitoneally or preperitoneally, diverting the bowel loop away from the defect. The “Keyhole” technique involves creating a slit in the mesh to accommodate the stoma, allowing the mesh to wrap around the bowel and provide lateral abdominal wall reinforcement. Some approaches combine elements of both, such as the “KeyBaker” technique, which aims to leverage the benefits of offsetting fascial defects while also providing lateral support.
The Recovery Process
Following parastomal hernia repair, patients typically remain in the hospital for 5 to 7 days; those with larger hernias might spend the first night in an intensive care unit for close monitoring. Hospital stay duration depends on the return of normal gastrointestinal function, adequate pain management, and the ability to move safely. Pain medication is provided to manage discomfort, which is usually most noticeable in the first week.
Upon returning home, wound care is a primary focus. Patients may have surgical drains in place to remove excess fluid, which are typically removed when fluid output decreases to around 30 milliliters per day for two consecutive days. Wounds are often covered with special skin glue or splash-proof dressings, allowing showering within 24 to 48 hours. Submerging the wound in a bath should be avoided for about a week. Some swelling, bruising, and a hard, lumpy feeling around the incision are normal as new scar tissue forms.
Dietary progression usually begins with liquids and advances as tolerated; a reduced appetite for a week or two is common due to surgical stress. Patients are encouraged to eat smaller, more frequent meals and may find protein shakes helpful for nutrition and hydration.
Activity restrictions are an important aspect of recovery to allow the repair to heal properly. Strenuous activities and heavy lifting (over 15 to 20 pounds) should be avoided for at least six weeks, with some sources recommending up to three months for full recovery. Gentle walking is encouraged from the day after surgery to promote circulation and prevent stiffness. Driving can typically resume within one to two weeks, once the individual can perform an emergency stop without pain. Return to light activities and work is often possible within one to two weeks; more strenuous work or exercises like jogging may require two to three months.
Risks and Recurrence of Parastomal Hernias
While parastomal hernia repair aims to improve patient comfort and stoma management, potential complications are associated with the procedure. Common surgical risks include bleeding and wound complications like infection or seromas (fluid collections). Specific risks include damage to the stoma or adjacent bowel, which can lead to complications like fistulas or strictures. In rare instances, mesh erosion into the bowel can occur, requiring further intervention.
Despite advancements in surgical techniques, the risk of hernia recurrence remains a significant concern. Recurrence rates vary by surgical method and patient factors, but can be substantial. Primary suture repair has a high recurrence rate, sometimes reaching 70 percent. Even with mesh reinforcement, rates for laparoscopic keyhole repair can be around 35 percent, while robotic Sugarbaker repair may see rates closer to 15 percent.
Factors Influencing Recurrence
Several factors can influence the likelihood of a parastomal hernia recurring. Patient-related factors include obesity, smoking, malnutrition, advanced age, and diabetes, all of which can impair healing and increase abdominal pressure. Surgical factors also play a role, such as ostomy type, stoma aperture size, and whether the stoma passes through the rectus abdominis muscle. Managing modifiable risk factors like weight and smoking status prior to surgery can contribute to a more favorable long-term outcome.