1. Management of the Parastomal Hernia
A Park MD FRCS FACS
University Of Maryland
Baltimore, MD

2. Overview: Some Background – definitions, demographics
Pathophysiology & mechanisms of formation
Clinical presentation
Management & Techniques of repair
How well are we doing?
Role of prophylaxis?

3. Defining Terms – Let’s Be Clear:
A parastomal hernia is an incisional hernia related to an abdominal wall stoma (Carne 2003)
…or even more broadly…
Any palpable defect or bulge adjacent to the stoma detected when the pt is supine with legs elevated or while…straining when the pt is erect (Israelsson 2008)

4. Devlin’s Classification of PH:
Helpful conceptually but of limited use clinical studies
4 types, difficult to distinguish in clinically:
i) subcutaneous
ii) interstitial
iii) perstomal
iv) intrastomal

5. Parastomal Hernias: Incidence
5% to 50% depending on definition & means of detection
Higher rates more accurate?!
Colostomy > ileostomy? Evidence limited
Lower with loops since shorter duration of stoma

6. Factors in Formation of Parastomal Hernias:
General pt factors (as with VH): obesity, malnutrition, COPD,  age, wound infection
Trephine size (?!):
- 1 vs 2 fingers (Babcock)
- 1.5 cm (colon) vs 2 cm (ileum)
- ⅔ width of “crushed” intestine (Nguyen)

7. Stoma Location & PH Formation:
Never through laparotomy incision! (infection, dehiscence, hernia)
Historically through umbilicus when paramedian incision used
Through rectus muscle vs lateral R.A
- limited evidence , no RCT data (2 of 6 retrospective studies suggest some benefit)
Pre op siting - no hernia advantage although more convenient & comfortable!

8. PH:Clinical Presentation
Most asymptomatic
Mild to life threatening (strangulation)
Often parastomal discomfort, int SBO
Difficulty with stoma appliance – skin irritation, soilage
Psychological issues- more difficult to conceal stoma , smell etc

9. Surgical Management of PH:
Local Suture Repair (50-100% recurrence)
Relocation of Stoma (36% recur BJS’03)
Mesh Repair
- Inlay vs Onlay vs IPOM (Sub/Underlay)
- Open vs Lap

10. Stoma Relocation Should be to contralateral side
- different quad same side… poor outcomes
Suture repair (only) of original site- 26% recurrence
Risk of recurrence at new site same as original(24-86%)even more if 2nd relocation

11. PH: Mesh Repair/Positioning
Inlay-no role ,recurrence too high
Onlay- on Anterior aponeurosis
- concern re:infection ++
- Intra abd pressure can displace mesh
- min. data (recur?10%) rarely done
Sublay or IPOM , preferred by most
- slit mesh vs “Sugarbaker”

12. PH: Open Mesh repair Results (Carne ’03, Israelsson ’08)
No prospective studies (let alone RCTs)
Data paltry, low recur. Short f/u (?)
Infection rates low …although…
Mesh related complications can be high
Presented opportunity for Lap approach

13. Rubin et al , Arch Surg 1994 68 parastomal repairs (55 patients)
f/u median 31 months
Local (fascial) repair- 36 (53%)
Stoma Relocation (37%)
Mesh Repair (mostly onlay) - 7 (10%)

14. Rubin (cont.) 63% overall recurrence Local repair -76%
Stoma Relocation- 33% (52% got incisional hernia)
Mesh repair - 30%

16. Berger et al (Dis Colon Rectum ‘07)
Retrospective study
66pts ( 22 recur hernias)- no conversions
“Sugarbaker” & slit double mesh technique
Median 24 mo f/u - 12% recurrence
3 major infections with mesh removal

18. Mancini et al (Surg Endosc ’07)
Multi-institute consecutive series
25 pts (6 recurrent hernias)- no conversions
Largely “Modified Sugarbaker”
Median f/u 19 mos. 4% recurrence
23% morbidity ( infectious,ileus,pulmonary)

20. Prevention of Parastomals (Janes, Israelsson et al BJS 2004)
Prospective Randomize Trial:
Pts undergoing colostomy w/wo sublay mesh
( light weight ,partially absorbable)
54 pts entered(27/27) - periop morbidity same
At 12mos f/u: 18 no mesh – 8 recurrences
16 with mesh – 0 recurrences
Study discontinued although f/u continues

21. Conclusions
Parastomal hernia remain a common sequela of stoma formation
(Mercifully) many are asymptomatic requiring no treatment
Surgical repair remains a challenge with suboptimal outctomes
Mesh repair (underlay) shows most promise
Must strongly consider prophylactic mesh