Overview
Definition:
A recurrent parastomal hernia is a bulge or protrusion of abdominal contents through a defect in the abdominal wall adjacent to a surgically created stoma, which has previously been repaired.
Epidemiology:
The incidence of parastomal hernia after colostomy varies from 4% to 50% in literature, with recurrence rates after initial repair being significant
Factors like BMI, stoma type (end colostomy vs
loop colostomy), and surgical technique influence incidence and recurrence.
Clinical Significance:
Recurrent parastomal hernias pose a challenge due to weakened abdominal wall integrity and proximity to the stoma
They can lead to stomal dysfunction, incarceration, strangulation, and significant patient discomfort, impacting quality of life and requiring surgical intervention.
Clinical Presentation
Symptoms:
Increasing bulge around the stoma, particularly with Valsalva maneuver
Pain or discomfort in the peristomal region
Difficulty managing the stoma appliance leading to leakage
Nausea and vomiting if incarceration occurs
Constipation or bowel obstruction symptoms in severe cases.
Signs:
Palpable bulge adjacent to the stoma, reducible with gentle pressure or lying down
Tenderness over the hernia sac
Signs of bowel obstruction (distended abdomen, absent bowel sounds) if incarcerated
Erythema or skin breakdown over the bulging area.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on physical examination findings of a peristomal bulge
Imaging (CT scan or ultrasound) may be used to confirm the diagnosis, delineate the hernia sac contents, and assess the abdominal wall defect, especially in recurrent cases or when clinical suspicion is high.
Diagnostic Approach
History Taking:
Detailed history of previous hernia repairs, stoma creation, and recurrence symptoms
Assess stoma function and appliance adherence
Inquire about any episodes of incarceration or strangulation
Evaluate comorbidities impacting surgical risk.
Physical Examination:
Careful inspection of the stoma and peristomal area
Palpation of the bulge in standing and supine positions, with Valsalva maneuver
Assess for reducibility and tenderness
Evaluate the integrity of the abdominal wall surrounding the stoma
Assess for signs of bowel obstruction.
Investigations:
CT scan of the abdomen and pelvis with the patient in both supine and erect positions, and potentially with Valsalva, is the preferred imaging modality
It helps define the hernia sac, its contents, and the size and location of the fascial defect
Ultrasound can be an alternative but is less definitive for full assessment of abdominal wall defects.
Differential Diagnosis:
Incisional hernia at other abdominal sites
Abdominal wall abscess
Desmoid tumor
Lipoma
Ventral hernia unrelated to the stoma
Adhesitis
Cellulitis of the abdominal wall.
Management
Initial Management:
Conservative management may involve a supportive garment or binder, but this is often ineffective for recurrent parastomal hernias and can increase risk of stomal complications
If symptoms are severe or signs of incarceration/strangulation are present, urgent surgical intervention is indicated.
Surgical Management:
The revised Sugarbaker technique is a key approach for recurrent parastomal hernias
It involves mobilizing the colon, reducing the hernia sac, and placing a prosthetic mesh
The key to the revised Sugarbaker is the retrocolic placement of the mesh, creating a new potential space between the visceral peritoneum and the posterior rectus sheath/muscles, thus avoiding direct mesh contact with the bowel and reducing recurrence and enterostomy complications
Recolonization of the hernia sac and repositioning of the stoma may also be considered.
Mesh Choice:
Synthetic mesh (e.g., polypropylene, ePTFE) or biologic mesh can be used, depending on surgeon preference and risk of infection
For complex recurrent cases, a dual-mesh approach may be considered.
Stoma Management:
The stoma may need to be repositioned to a healthier abdominal wall site to ensure adequate blood supply and reduce tension on the repaired area
Careful stoma siting is crucial for long-term success.
Complications
Early Complications:
Mesh infection
Mesh migration
Wound dehiscence
Seroma formation
Stoma ischemia or necrosis
Bowel injury during dissection
Anastomotic leak if bowel resection and anastomosis is performed.
Late Complications:
Recurrence of the parastomal hernia
Chronic mesh infection
Enterostomy complications such as stenosis or retraction
Adhesions
Chronic pain syndrome
Fistula formation.
Prevention Strategies:
Meticulous surgical technique to ensure adequate mesh coverage and fixation
Avoid direct contact between the mesh and the bowel, particularly in the revised Sugarbaker technique
Optimize stoma siting
Counsel patients on risk factors for recurrence
Judicious use of prosthetic material.
Prognosis
Factors Affecting Prognosis:
The success of the repair is influenced by the extent of abdominal wall defect, patient comorbidities (obesity, diabetes), previous surgical history, and adherence to postoperative care
The revised Sugarbaker technique generally offers better outcomes for recurrence compared to older methods.
Outcomes:
With appropriate surgical repair, particularly using the revised Sugarbaker technique, recurrence rates can be significantly reduced
Patient quality of life is often improved by alleviating symptoms and enabling better stoma management.
Follow Up:
Regular follow-up is essential, initially with wound checks and stoma assessment, followed by periodic clinical review to monitor for recurrence or stomal complications
Imaging may be employed if suspicion of recurrence arises.
Key Points
Exam Focus:
Understand the rationale behind the revised Sugarbaker technique: retrocolic mesh placement to minimize enterostomy complications
Differentiate it from anterior mesh placement
Know the indications for surgical repair of parastomal hernias
Recognize complications like incarceration and strangulation.
Clinical Pearls:
Always consider recurrent parastomal hernia in patients with stomal issues and a peristomal bulge
Preoperative imaging is vital for planning recurrent repairs
Careful stoma siting is as important as the hernia repair itself
The revised Sugarbaker aims to create a "new" fascial plane for mesh placement, distinct from previous repairs.
Common Mistakes:
Placing mesh directly against the bowel (leading to enterostomy complications or erosion)
Inadequate mesh overlap
Poor stoma siting, leading to tension or poor appliance seal
Not considering recurrence as a possibility in patients with previously repaired hernias or developing stoma issues.