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Parastomal hernia Dr Chan Wai Hei, Arthur Queen Elizabth Hospital.

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Presentation on theme: "Parastomal hernia Dr Chan Wai Hei, Arthur Queen Elizabth Hospital."— Presentation transcript:

1 Parastomal hernia Dr Chan Wai Hei, Arthur Queen Elizabth Hospital

2 Overview Background Background Classification Classification Risk factors Risk factors Clinical presentation & Complications requiring surgical intervention Clinical presentation & Complications requiring surgical intervention Management Management Prevention Prevention

3 Definition A parastomal hernia (PSH) is a type of incisional hernia that occurs at the site of stoma or immediately adjacent to the stoma A parastomal hernia (PSH) is a type of incisional hernia that occurs at the site of stoma or immediately adjacent to the stoma The most common late complication of a permanent stoma The most common late complication of a permanent stoma

4 Incidence Variable incidence reported in literature Variable incidence reported in literature Incidence increases with time Incidence increases with time Most occur within 2 years of stoma formation Most occur within 2 years of stoma formation Some believe that it is an inevitable consequence of stoma formation Some believe that it is an inevitable consequence of stoma formation

5 Incidence [Pilgrim CH, McIntyre R, Bailey M. Prospective audit of parastomal hernia: prevalence and associated comorbidities. Dis Colon Rectum 2010;53:71-6]

6 Incidence Literature review by Carne et al. Literature review by Carne et al % in end ileostomies % in end ileostomies 0-6.2% in loop ileostomies 0-6.2% in loop ileostomies % in end colostomies % in end colostomies % in loop colostomies % in loop colostomies [Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784-93]

7 Classification Traditional Traditional Radiological Radiological

8 Classification - Traditional 4 subtypes 4 subtypes 1) Subcutaneous 1) Subcutaneous most common type most common type the herniation enters into the subcutaneous fat alongside the stoma the herniation enters into the subcutaneous fat alongside the stoma 2) Interstitial 2) Interstitial the herniation extrudes alongside the bowel for stoma, then burrows into one of the intermuscular planes the herniation extrudes alongside the bowel for stoma, then burrows into one of the intermuscular planes 3) Peristomal 3) Peristomal the stomal bowel is prolapsed and loops of bowel and/or omentum enter the hernia space produced between the layers of prolapsed bowel the stomal bowel is prolapsed and loops of bowel and/or omentum enter the hernia space produced between the layers of prolapsed bowel 4) Intrastomal 4) Intrastomal enters the plane between the merging and the everted part of bowel enters the plane between the merging and the everted part of bowel usually occurs in the spout type of stoma – e.g. ileostomy usually occurs in the spout type of stoma – e.g. ileostomy [Devlin HB. Peristomal hernia. In: Operative Surgery Volume 1: Alimentary Tract and Abdominal Wall, 4th ed, Dudley H (Ed), Butterworths, London p.441.]

9 Classification - Radiological [Moreno-matias J, Serra-aracil X, Darnell-martin A et-al. The prevalence of parastomal hernia after formation of an end colostomy. A new clinico-radiological classification. Colorectal Dis. 2009;11 (2): 173-7] type Ia type Ib type II type III

10 Risk factors Patient-related Patient-related Surgery-related Surgery-related

11 Patient-related risk factors Age Age Obesity (>30kg/m2) and waist circumference (>100cm) Obesity (>30kg/m2) and waist circumference (>100cm) Poor nutritional status Poor nutritional status Increased intraabdominal pressure (COAD, constipation, BPH, ascites, etc) Increased intraabdominal pressure (COAD, constipation, BPH, ascites, etc) Connective tissue disorders Connective tissue disorders Immunosuppressive drugs (e.g. corticosteroids) Immunosuppressive drugs (e.g. corticosteroids) Other disease predispose to wound infection (e.g. DM) Other disease predispose to wound infection (e.g. DM) Other underlying diseases (e.g. IBD, malignancy) Other underlying diseases (e.g. IBD, malignancy)

12 Surgery-related risk factors Emergency construction of stoma Emergency construction of stoma Stoma lateral to rectus muscle Stoma lateral to rectus muscle Diameter of trephine Diameter of trephine defect >3cm was found to be associated with a higher incidence of herniation, independent of stoma type defect >3cm was found to be associated with a higher incidence of herniation, independent of stoma type currently few data to base advice about the appropriate size of abd wall opening currently few data to base advice about the appropriate size of abd wall opening suggestions of not more than 2.5cm had been made suggestions of not more than 2.5cm had been made smallest opening that allows the creation of a viable stoma without ischaemia appears to be the best guide smallest opening that allows the creation of a viable stoma without ischaemia appears to be the best guide Closure of lateral space Closure of lateral space Stoma fixation to fascia Stoma fixation to fascia Intraperitoneal or extraperitoneal approach Intraperitoneal or extraperitoneal approach

13 Clinical presentation Vary from asymptomatic to life-threatening strangulation Vary from asymptomatic to life-threatening strangulation Typically – bulge at the site of or adjacent to the stoma, with or without pain Typically – bulge at the site of or adjacent to the stoma, with or without pain Mild abd discomfort, intermittent colic, distention, nausea & vomiting, diarrhoea, constipation and a reducible hernia Mild abd discomfort, intermittent colic, distention, nausea & vomiting, diarrhoea, constipation and a reducible hernia Physical examination – on lying down and standing with valsalva Physical examination – on lying down and standing with valsalva Digital examination enables the fascial aperture and parastomal tissues to be assessed Digital examination enables the fascial aperture and parastomal tissues to be assessed

14 Complications requiring surgery Literature reported a range of 11%-70% Literature reported a range of 11%-70% Local data: ~32% require surgical intervention Local data: ~32% require surgical intervention Urgent surgery for strangulation of an irreducible hernia Urgent surgery for strangulation of an irreducible hernia Following signs & symptoms can be repaired electively Following signs & symptoms can be repaired electively increasing size increasing size intermitted bowel obstructions intermitted bowel obstructions chronic abdominal pain related to PSH chronic abdominal pain related to PSH ill-fitting appliance and leakage ill-fitting appliance and leakage peristomal skin breakdown peristomal skin breakdown other stoma complications other stoma complications

15 Management Conservative Conservative Surgery Surgery Closure of stoma Closure of stoma Direct fascial repair Direct fascial repair Relocation Relocation Mesh repair Mesh repair Different location Different location Lap vs open Lap vs open Laparoscopic techniques Laparoscopic techniques Prevention Prevention

16 Direct fascial repair Reduce size of hernia defect by reapproximating the fascial edges of trephine with sutures Reduce size of hernia defect by reapproximating the fascial edges of trephine with sutures Advantage Advantage simple technique simple technique avoids laparotomy avoids laparotomy low complication rate in elective operation low complication rate in elective operation may have a role when there is a strong desire to avoid mesh or more major surgery may have a role when there is a strong desire to avoid mesh or more major surgery Disadvantage Disadvantage excessive tension and subsequent failure in large fascial defect excessive tension and subsequent failure in large fascial defect high recurrence rate – reported in various literature to be % high recurrence rate – reported in various literature to be %

17 Relocation This approach avoided because the new stoma at new site is associated with the same high risk of hernia formation This approach avoided because the new stoma at new site is associated with the same high risk of hernia formation Some authors reported a lower recurrence rate after relocation to other side of abdominal wall than relocation on the same side of abdomen Some authors reported a lower recurrence rate after relocation to other side of abdominal wall than relocation on the same side of abdomen Advantage Advantage useful if the current stoma position unsatisfactory useful if the current stoma position unsatisfactory can be done with or without laparotomy can be done with or without laparotomy lower recurrence rate than direct fascial repair lower recurrence rate than direct fascial repair Disadvantage Disadvantage local recurrence rate reported in literature ~36.3% (range up to 76.2%) local recurrence rate reported in literature ~36.3% (range up to 76.2%) not feasible if patient has multiple previous scars not feasible if patient has multiple previous scars risk of incisional hernia at the site of the original stoma or midline wound risk of incisional hernia at the site of the original stoma or midline wound more risk of morbidity if require laparotomy more risk of morbidity if require laparotomy [Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784-93]

18 Mesh repair Overall recurrence rates after mesh repair vary between % (depending on technique and placement of mesh) Overall recurrence rates after mesh repair vary between % (depending on technique and placement of mesh) Overall mesh infection rate 2.4% Overall mesh infection rate 2.4% Risk of mesh infection did not differ between mesh techniques Risk of mesh infection did not differ between mesh techniques [HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a systematic review of literature. Ann Surg 255(4): ]

19 Different anatomical locations of mesh [Israelsson LA. Parastomal hernias. Surg Clin North Am. 2008;88: ]

20 Onlay technique First described by Rosin and Bonardi in 1977 First described by Rosin and Bonardi in 1977 Mesh placed subcutaneously and fixed onto the anterior rectus aponeurosis Mesh placed subcutaneously and fixed onto the anterior rectus aponeurosis Prefascial plane was entered through a lateral parastomal incision Prefascial plane was entered through a lateral parastomal incision After reduction of hernia sac, the fascial opening was narrowed with sutures and mesh was placed to reinforce the suture repair After reduction of hernia sac, the fascial opening was narrowed with sutures and mesh was placed to reinforce the suture repair Advantage: Advantage: more straight forward surgical technique involving a mesh more straight forward surgical technique involving a mesh avoids intra-abdominal dissection avoids intra-abdominal dissection Disadvantage Disadvantage associated with higher risk of contamination & sepsis than sublay technique associated with higher risk of contamination & sepsis than sublay technique extensive dissection of subcutaneous tissue extensive dissection of subcutaneous tissue predisposes to haematoma / seroma formation predisposes to haematoma / seroma formation undermining is a risk for ischaemic injury to skin => impair wound healing undermining is a risk for ischaemic injury to skin => impair wound healing intraabdominal pressure may lead to detachment of mesh resulting in recurrence intraabdominal pressure may lead to detachment of mesh resulting in recurrence

21 Onlay technique [HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a systematic review of literature. Ann Surg 255(4): ]

22 Sublay technique Mesh placed between rectus muscle and posterior sheath Mesh placed between rectus muscle and posterior sheath Fewer studies evaluating this method of mesh placement Fewer studies evaluating this method of mesh placement Small series with relatively short follow up (most <12mo) Small series with relatively short follow up (most <12mo) Overall recurrence rate 6.9% Overall recurrence rate 6.9% Advantage Advantage intraabdominal pressure does not dislocate the mesh from repair intraabdominal pressure does not dislocate the mesh from repair no direct contact with bowel no direct contact with bowel Disadvantage Disadvantage more technically challenging than onlay technique more technically challenging than onlay technique

23 Inlay tecnique Mesh cut to size of abdominal wall defect, placed within fascial defect and sutured to fascial edges Mesh cut to size of abdominal wall defect, placed within fascial defect and sutured to fascial edges Abandoned because of high failure rates Abandoned because of high failure rates

24 Intraperitoneal onlay position (IPOM) Mesh placed intraabdominally on the peritoneum Mesh placed intraabdominally on the peritoneum 2 techniques – keyhole or Sugarbaker 2 techniques – keyhole or Sugarbaker Keyhole technique Sugarbaker technique [HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a systematic review of literature. Ann Surg 255(4): ]

25 Sugarbaker technique Sugarbaker first described his technique in 1980 Sugarbaker first described his technique in 1980 Technique: Technique: trephine opening is covered with an intraperitoneally placed mesh via a laparotomy and sutured to fascial edge trephine opening is covered with an intraperitoneally placed mesh via a laparotomy and sutured to fascial edge bowel is lateralized passing from hernia sac between the abdominal wall and mesh into the peritoneal cavity bowel is lateralized passing from hernia sac between the abdominal wall and mesh into the peritoneal cavity later modified to provide at least 5cm overlap of mesh and adjacent fascia later modified to provide at least 5cm overlap of mesh and adjacent fascia Advantage Advantage generous mesh overlap generous mesh overlap flap valve effect created able to withstand increased intraabdominal pressure flap valve effect created able to withstand increased intraabdominal pressure Disadvantage Disadvantage mesh related complications mesh related complications dense adhesions causing intestinal obstruction requiring laparotomy dense adhesions causing intestinal obstruction requiring laparotomy bowel erosion & fistula formation bowel erosion & fistula formation Main application of these techniques is in laparoscopic repair Main application of these techniques is in laparoscopic repair

26 IPOM [HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a systematic review of literature. Ann Surg 255(4): ]

27 Laparscopic techniques Key-hole vs modified sugarbaker vs sandwich technique Key-hole vs modified sugarbaker vs sandwich technique Potential advantages Potential advantages minimal additional injury to abdominal wall which is already at risk of herniation minimal additional injury to abdominal wall which is already at risk of herniation better view of defect allowing more precise repair and reinforcement with a mesh better view of defect allowing more precise repair and reinforcement with a mesh concomitant incisional hernia repair concomitant incisional hernia repair faster postop recovery and decreased postop pain faster postop recovery and decreased postop pain Sandwich technique Sandwich technique [Berger D, Bientzle M. Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair. A prospective, observational study with 344 patients. Hernia. 2009;13: ]

28 Laparoscopic techniques Key-hole vs modified sugarbaker vs sandwich technique Key-hole vs modified sugarbaker vs sandwich technique Recurrence rate: Recurrence rate: Keyhole 34.6% Keyhole 34.6% Sugarbaker 11.6% Sugarbaker 11.6% Sandwich 2.1% Sandwich 2.1% Conversion rate 3.6% Conversion rate 3.6% reasons: multiple dense adhesions, bowel injury, inaccessible abdomen reasons: multiple dense adhesions, bowel injury, inaccessible abdomen Mesh infection rate 2.7% Mesh infection rate 2.7% Wound infection 3.3% Wound infection 3.3% Other complication rates 12.7% Other complication rates 12.7% bowel injury 4.1% (15/363) bowel injury 4.1% (15/363) 5 repaired laparoscopically (1 hernia repair was postponed) 5 repaired laparoscopically (1 hernia repair was postponed) 6 converted to open 6 converted to open 4 were undetected (small bowel injury) during operation (3 required reoperation, 1 resulted in multiorgan failure and death) 4 were undetected (small bowel injury) during operation (3 required reoperation, 1 resulted in multiorgan failure and death)

29 Lap vs Open techniques Mesh techniques did not differ significantly in terms of recurrence Mesh techniques did not differ significantly in terms of recurrence Overall laparoscopic repair had no advantage over open repair Overall laparoscopic repair had no advantage over open repair [HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a systematic review of literature. Ann Surg 255(4): ]

30 Prevention High incidence of parastomal hernia together with unsatisfactory results of its repair and morbidity associated with operation lead to emphasis on prevention High incidence of parastomal hernia together with unsatisfactory results of its repair and morbidity associated with operation lead to emphasis on prevention Prevention strategies Prevention strategies surgical techniques surgical techniques prophylactic mesh insertion prophylactic mesh insertion

31 Surgical techniques in prevention Through or lateral rectus abdominis Through or lateral rectus abdominis only retrospective studies found lower rate of PSH with stomas formed through the rectus muscle only retrospective studies found lower rate of PSH with stomas formed through the rectus muscle nonetheless probably wise to bring out stoma throught rectus abdominis ms as this is not associated with any disadvantage nonetheless probably wise to bring out stoma throught rectus abdominis ms as this is not associated with any disadvantage Fascial fixation Fascial fixation Closure of lateral space Closure of lateral space Trephine size Trephine size Extraperitoneal route for stoma construction Extraperitoneal route for stoma construction

32 Extraperitoneal route for permanent colostomy Few studies had shown that extraperitoneal approach can achieve lower risk of herniation than transperitoneal route Few studies had shown that extraperitoneal approach can achieve lower risk of herniation than transperitoneal route Potential disadvantage Potential disadvantage longer operative time longer operative time may need mobilization of splenic flexure for extra length may need mobilization of splenic flexure for extra length Goligher first published the formation of extraperitoneal colostomy in 1958 Goligher first published the formation of extraperitoneal colostomy in 1958 extraperitoneal route provides an oblique passage of bowel and eliminate the lateral peritoneal space without using suture extraperitoneal route provides an oblique passage of bowel and eliminate the lateral peritoneal space without using suture attempt to reduce risk of postop small bowel obstruction due to internal herniation into lateral peritoneal space and reduce parastomal hernia attempt to reduce risk of postop small bowel obstruction due to internal herniation into lateral peritoneal space and reduce parastomal hernia Since then, subsequent studies have been published with inconsistent results Since then, subsequent studies have been published with inconsistent results Only 2 retrospective studies found extraperitoneal colostomy construction was associated with a lower rate of parastomal herniation than intraperitoneal route Only 2 retrospective studies found extraperitoneal colostomy construction was associated with a lower rate of parastomal herniation than intraperitoneal route most studies were observational retrospective studies with small numbers of patients undergoing extraperitoneal colostomy and follow up period was not mentioned most studies were observational retrospective studies with small numbers of patients undergoing extraperitoneal colostomy and follow up period was not mentioned Studies of highter quality, including RCTS with larger no. of patients are needed Studies of highter quality, including RCTS with larger no. of patients are needed

33 Prophylactic mesh insertion Bayer and colleagues first described mesh insertion at the time of primary stoma formation in 1986 Bayer and colleagues first described mesh insertion at the time of primary stoma formation in 1986 Since then many observational studies confirmed the safety and effectiveness of prophylactic mesh insertion with low morbidity Since then many observational studies confirmed the safety and effectiveness of prophylactic mesh insertion with low morbidity Three RCTs ( ) have shown that prophylactic mesh in sublay position is associated with reduction in parastomal hernia when compared with standard stoma formation Three RCTs ( ) have shown that prophylactic mesh in sublay position is associated with reduction in parastomal hernia when compared with standard stoma formation Systematic review including the three RCTs found a statistically significant difference in the incidence of PSH in the mesh gp 12.5% and in the no-mesh gp 53%, but no difference in morbidity Systematic review including the three RCTs found a statistically significant difference in the incidence of PSH in the mesh gp 12.5% and in the no-mesh gp 53%, but no difference in morbidity [Shabbir J, Chaudhary BN, Dawson R. A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation. Colorectal Dis 2012;14(8):931-6.]

34 RCTs Study Patient types No. of patients Type of mesh Operative technique Serra Araci l elective Mesh 27, no mesh 27 Ultrapro (polypropylene + polygelcaprone 25) Sublay Janes elective & emergen cy Mesh 27, no mesh 27 Vypro (polypropylene + polyglactin 910) Sublay Hammon d elective Mesh 10, no mesh 10 Permacol (porcine derived crosslinked collagen implant) Sublay

35 RCTs (cont) Loss to follow up Study Randomiz ation Blindin g Evaluation of hernia Follow up / months MeshNo mesh Serra Aracil sealed envelop e assess or Physical examination + CT abdomen Median 29 (range 13-49) 00 Janes not mention ed assess or Physical examination only Mean 65.2 (range 57-83) 6/27 at 12mo, 6/21 between 1-5yrs 1/27 before 12mo, 5/26 betwee n 1- 5yrs Hammon d sealed envelop e double Physical examination + stoma site USG Median 6.5 (range 1- 12) 0 0

36 RCTs (cont) Parastomal hernia Infection StudyMesh No mesh Mesh Mesh complicatio ns Serra Aracil 6/27 (22.2%) 12/27 (44.4%) 1/27 (3.7%) 0 Janes 2/15 (13%) 17/21 (81%) 000 Hammon d 0/10 (0%) 3/10 (30%) 000

37 Conclusion Concerning repair Concerning repair Mesh repair result in lower recurrence rate Mesh repair result in lower recurrence rate Mesh techniques did not differ significantly in terms of recurrence or morbidity Mesh techniques did not differ significantly in terms of recurrence or morbidity Low overall rate of mesh infection and comparable for each mesh repair Low overall rate of mesh infection and comparable for each mesh repair Overall laparoscopic repair had no advantage over open repair Overall laparoscopic repair had no advantage over open repair Concerning prevention Concerning prevention Meticulous surgical technique Meticulous surgical technique Adequately powered RCTs is still needed before recommendation of prophylactic mesh insertion Adequately powered RCTs is still needed before recommendation of prophylactic mesh insertion

38 Discussion


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