Parastomal Hernia

What is a Parastomal Hernia? 

A parastomal hernia is a complication after a previous abdominal surgery in which a stoma was created. It involves the pathological movement of the hernial sac containing abdominal contents, typically the small intestine, through an opening in the abdominal wall adjacent to the stoma. Unfortunately, it occurs in up to 50% of such patients within two years, although sometimes they may appear much later. There are two types of parastomal hernias:

• True parastomal hernia, where the opening created in the abdominal wall for the stoma was too wide, allowing the hernia to bulge through
• Pseudo parastomal hernia, where the tissue around the stoma weakens over time to allow the hernia to pass through the stomal opening

Parastomal Hernia – Causes 

The opening around the stoma widens due to a combination of sheering forces that weaken the abdominal wall over time, and increased intraabdominal pressure caused by sneezing, coughing, vomiting, or lifting heavy objects. Additional risk factors include:

• Aging
• Female gender
• Obesity
• Smoking
• Steroid therapy
• Chronic constipation
• Chronic obstructive pulmonary disease
• Diabetes
• Waist circumference over 100cm
• Malnutrition
• Previous parastomal hernia
• Postoperative wound complications, including infection after stoma surgery
• Abnormal stoma formation
• Large intestinal stoma
• Emergency surgery for peritonitis or intestinal obstruction
• Other hernias due to congenital fascia weakness

Parastomal Hernia – Symptoms

A characteristic symptom of a parastomal hernia is a soft lump in the stoma area that increases in size over time. This lump often gets smaller when the patient is lying down but is visible when standing or sitting upright, as well as during activities that increase intraabdominal pressure such as sneezing, coughing, or lifting heavy objects. Over time, an enlarging hernia can cause problems with stomal function, defecation disturbances, and adhesions within the hernia. Incarceration refers to the failure of the hernial sac to spontaneously return to the abdominal cavity, typically resulting in compromised blood flow to the hernia contents through a process called strangulation. Early symptoms are similar to intestinal obstruction and include fever, vomiting, pain around the stoma, and gas and stool retention. Should any of these occur, emergency surgical intervention is required as strangulated hernias are potentially fatal complications.

Parastomal Hernia – Diagnosis

Parastomal hernias are diagnosed by careful palpation, during which a physician looks for a characteristic subcutaneous bulge around the stoma that enlarges with coughing or bearing down. Sometimes, an abdominal ultrasound is indicated to confirm the diagnosis. It is important to note that parastomal hernias do not spontaneously resolve and may lead to life-threatening complications due to incarceration and strangulation of the hernia. Surgery is therefore necessary if a parastomal hernia is diagnosed.

Parastomal Hernia – Treatment

There are preventative measures that reduce the likelihood of postoperative parastomal hernias, such as surgeons placing a medical polypropylene mesh around the stoma after creating it to reinforce the area, or by patients starting to wear a hernia belt early in the recovery period. However, should these measures fail and the hernia becomes strangulated, surgical intervention is always necessary. Proactive surgical correction is therefore advisable to mitigate this risk. In the past, surgeons would repair a parastomal hernia by moving the stoma to a different location and suturing closed the original defect, or by narrowing the original opening with sutures. However, these techniques were associated with a high risk for hernia recurrence and have been replaced by the Sugarbaker procedure where a reinforcing mesh is placed around the parastomal area. A European multicenter study found that this method reduced the hernia recurrence rate to less than 7% at two years postoperatively, as compared to nearly 70% using traditional methods. Incidentally, over 40% of these patients were found to also have a secondary incisional hernia that was successfully repaired by the Sugarbaker procedure. Due to the complexity involved in parastomal hernia repair, it is mainly performed using minimally invasive techniques, i.e., laparoscopic or robotic surgery. Systematic reviews of the scientific literature have shown that minimally invasive techniques allow surgeons to better visualize and repair the defect causing a parastomal hernia as compared to the classic (open) method. Minimally invasive techniques avoid making another large incision in the skin. Instead, access is achieved using only 3-5 much smaller incisions whose diameter is less than 1cm. These tiny openings serve as gates for all the surgical instruments, including an endoscopic camera to properly visualize the area. Minimally invasive surgery offers patients several key advantages over classic, open techniques. Namely, there is less intraoperative blood loss and a lower risk of surgical site infection. The postoperative recovery period is also shorter and less painful, allowing patients to return to their daily routines sooner. Finally, scars are often barely visible when healed, achieving a vastly superior cosmetic effect for patients as compared with classic, open surgery.

Parastomal Hernia – Recovery

Hospitalization after parastomal hernia repair depends on the extent of the procedure and the method used. However, one can expect to remain hospitalized for about 1-3 days. The recovery period ranges from 4 to 6 weeks, and also depends on what the indication for creating a stoma was, and any adjuvant therapy. However, patients must avoid lifting heavy objects or intense physical exertion for 4 – 6 weeks.

Parastomal Hernia – Price

The price of a parastomal hernia repair depends on the type of hernia, its location, the type of mesh used to reinforce the abdominal wall, the type of anesthesia used (local or general), and whether it is done classically, laparoscopically, or robotically. All details of the operation and possible treatment options are always discussed together with the attending physician during the initial consultation where you are qualified for the procedure.