Overview
Definition:
A parastomal hernia is the protrusion of abdominal contents through an abdominal wall defect adjacent to a surgically created stoma (colostomy or ileostomy)
The Sugarbaker technique is a popular mesh-based repair for parastomal hernias, involving the placement of a prosthetic mesh to reinforce the abdominal wall defect and prevent recurrence.
Epidemiology:
Parastomal hernias occur in approximately 10-40% of patients with end colostomies and 5-20% with end ileostomies
The incidence increases with time post-stoma creation, often presenting within 1-2 years
Risk factors include stoma site choice, BMI, and wound complications.
Clinical Significance:
Parastomal hernias can cause cosmetic disfigurement, discomfort, pain, and complications such as stoma retraction, bowel obstruction, strangulation, and impaired stoma function, significantly impacting patient quality of life
Timely and effective repair is crucial.
Clinical Presentation
Symptoms:
A visible or palpable bulge adjacent to the stoma, which may be reducible
Discomfort or pain in the perisomial area
Difficulty with stoma appliance fitting
Symptoms of bowel obstruction if strangulation occurs, such as nausea, vomiting, abdominal distension, and absent bowel sounds
Irritation or breakdown of the peristomal skin due to appliance issues.
Signs:
A reducible or irreducible bulge in the perisomial region
Increased intra-abdominal pressure (e.g., Valsalva maneuver) may accentuate the bulge
Tenderness on palpation, especially if incarcerated or strangulated
Signs of bowel obstruction may be present.
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by imaging
A visible or palpable bulge adjacent to a stoma, often exacerbated by increased intra-abdominal pressure
Imaging may show herniation of visceral fat or bowel loops through the abdominal wall defect near the stoma.
Diagnostic Approach
History Taking:
Detailed history of stoma creation, duration, and type
Onset and progression of perisomial bulge and associated symptoms
Previous abdominal surgeries
Any history of bowel obstruction or incarceration
Patient's functional status and impact on quality of life.
Physical Examination:
Thorough abdominal examination with particular attention to the stoma and surrounding area
Assess for bulge with and without straining
Palpate the defect and reducibility
Evaluate peristomal skin integrity
Auscultate bowel sounds
Assess for signs of strangulation (tenderness, guarding, rigidity).
Investigations:
Ultrasound of the abdominal wall can detect the hernia sac and contents
CT scan of the abdomen and pelvis is the gold standard, demonstrating the defect, herniated contents, and relationship to the mesh (if previous repair)
It helps rule out other intra-abdominal pathology
Barium studies are rarely needed.
Differential Diagnosis:
Incisional hernia at the stoma site itself (though typically located within the stoma orifice rather than adjacent)
Intra-abdominal abscess
Desmoid tumor
Adnexal mass (in females)
Lipoma or other soft tissue masses
Rectus sheath hematoma.
Management
Initial Management:
For asymptomatic hernias, conservative management may be considered, focusing on patient education regarding symptom monitoring and proper stoma appliance use
Symptomatic or complicated hernias require surgical intervention
Reduction of incarcerated contents if possible without excessive force.
Medical Management:
Primarily supportive
Pain management with analgesics
Management of nausea and vomiting with antiemetics
Bowel rest and nasogastric decompression if bowel obstruction is present
Antibiotics if infection or strangulation is suspected
Nutritional support as needed.
Surgical Management:
The Sugarbaker technique is the primary surgical approach
Indications include symptomatic hernias, incarcerated hernias, or hernias causing significant cosmetic or functional impairment
The goal is to reinforce the abdominal wall defect with a prosthetic mesh.
Postoperative Care:
Pain management
Early mobilization
Gradual diet advancement
Close monitoring for wound complications, mesh infection, or hernia recurrence
Stoma care and patient education on long-term management
Early ambulation is encouraged
Antibioprophylaxis is standard.
Sugarbaker Technique Details
Rationale:
To provide durable repair by bridging the defect with a mesh and incorporating the lateral stoma border to prevent recurrence.
Procedure Steps:
Incision is made around the stoma and the hernia sac
The hernia sac is dissected free from surrounding tissues
The abdominal contents are reduced
A large piece of prosthetic mesh (e.g., polypropylene or composite) is prepared
The mesh is typically placed in a keyhole fashion, with the stoma aperture passing through the mesh
The edges of the mesh are then secured to the abdominal wall, usually to the anterior rectus sheath and posterior fascia, creating a "sandwich" effect with the stoma residing within the mesh's central opening
Care is taken to avoid tension on the mesh and surrounding tissues.
Mesh Placement:
The mesh is strategically positioned to cover the fascial defect adjacent to the stoma
It is typically sutured to the anterior and posterior rectus sheath, creating a double-layer reinforcement
The stoma is brought through a central opening in the mesh.
Closure:
The subcutaneous tissues and skin are closed in layers
Care is taken to ensure adequate stoma viability and to avoid undue tension on the stoma or peristomal skin.
Complications
Early Complications:
Wound infection
Mesh infection
Seroma formation
Hematoma
Stoma ischemia or necrosis
Bowel obstruction
Pain at the mesh site
Injury to adjacent bowel loops or abdominal organs during mesh placement.
Late Complications:
Hernia recurrence
Chronic pain
Mesh-related complications (e.g., erosion, migration, fistula formation, although less common with open repair)
Adhesions.
Prevention Strategies:
Meticulous surgical technique to minimize tissue trauma
Proper sterile technique during surgery
Judicious use of drains if necessary
Appropriate mesh selection and fixation
Careful dissection to avoid injury
Patient selection and optimization of comorbidities
Postoperative antibiotics.
Prognosis
Factors Affecting Prognosis:
Size and complexity of the hernia
Patient comorbidities (obesity, diabetes, immunosuppression)
Surgical technique employed
Development of postoperative complications
Patient compliance with postoperative instructions.
Outcomes:
Successful Sugarbaker repair typically leads to resolution of symptoms and prevention of recurrence in a high percentage of patients
Recurrence rates vary but are generally reported between 5-20%
Quality of life improvement is significant for symptomatic patients.
Follow Up:
Regular follow-up appointments are recommended, particularly in the first year post-surgery, to monitor for signs of recurrence or complications
Patients should be educated on self-monitoring and to report any new or worsening symptoms promptly.
Key Points
Exam Focus:
Understand the indications for parastomal hernia repair
Be familiar with the steps of the Sugarbaker technique, including mesh placement and fixation
Know the common early and late complications and their management
Differentiate parastomal hernia from stoma site hernias.
Clinical Pearls:
A good stoma site choice during the initial surgery is paramount to prevent parastomal hernias
The Sugarbaker technique aims to create a "sandwich" of mesh around the stoma
Consider mesh infection as a serious complication requiring aggressive management, potentially mesh explantation.
Common Mistakes:
Inadequate dissection of the hernia sac
Insufficient mesh coverage of the fascial defect
Over-tensioning of the mesh or stoma
Failing to recognize and manage incarcerated or strangulated bowel
Inadequate postoperative care and patient education leading to non-compliance or recurrence.