1. Parastomal Hernia Repair
C R Kapadia
Airedale General Hospital
Good Afternoon
Thank you for allowing me to speak today, some of you may have heard this in Hong Kong, so I will apologise
I wish to present a review of patients who have had laparoscopic Para Stomal Hernia repair- A t the time of these being undertaken it was and still is a recently new technique in the UK but has been in Europe a couple of years
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2. Parastomal Hernia
“Some degree of herniation around a colostomy is so common that this complication may be regarded as inevitable”
Goligher

3. Parastomal Hernia
An Incisional Hernia related to an abdominal wall stoma.
Particularly noticeable on tensing the abdominal wall muscles- coughing, sneezing, straining or standing.
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4. Para Stomal Hernia
Parastomal herniation is not uncommon and the management of a parastomal hernia is a common clinical dilemma.
Once such a hernia is established, it is difficult to treat, and many operative factors have been claimed to influence its occurrence and many techniques of repair have been described.
[Carne, Robertson and Frizelle]
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5. Incidence of Parastomal Hernia
0 – 48% depending on type of stoma and length of follow up
[Carne, PWG; Robertson, GM; Frizelle, FA. 2003]
20-25% Commoner in end colostomy
[Devlin, 1982]
67% transverse loop colostomy
[Nordstrum &Hulten, 1987]
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6. Incidence of Parastomal Hernia
50% Colostomy
[Nugent, 1999]
28% Ileostomy
[Williams, 1990]
5-8% Urostomy
[Rubin & Bailey1993]
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7. Diagnosis History Examination - Standing - Lying Valsalva manoeuvre
Digital examination of stoma
CT Scan

8. Classification (Devlin)
Interstitial
Subcutaneous
Intrastomal
Peristomal

9. Risk Factors Intrinsic Extrinsic Age Obesity Wound Infection Smoking
Emergency Surgery
Location of Stoma
Previous repair

10. Treatment
Restore continuity of the intestine

11. Indications for Surgical Repair
Strangulation
Obstruction
Fistula formation
Ischaemia
Pain
Body Image - patient expectation
Gross disfiguration causing psychological distress and social isolation due to the deformity
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12. Choice of Surgical Procedures
1. Stoma Relocation
2. Local Tissue Repair
3. Prosthetic Repair - intraperitoneal
- extraperitoneal
- fascial onlay
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13. Surgical Repair Increased infection rates
Recurrence 39% [Reiger, 2004]
Complications 57% [Hughes, 1999]
Laparoscopic repair with mesh 10% recurrence [Le Blanc, 2004]
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14. Laparoscopic Surgery
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15. Cost Effectiveness Decreased:
Chest infection Wound infection Adhesion complications Earlier recovery Shorter patient stay Better productivity
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16. Advantages of Laparoscopy
Direct magnified vision allowing identification of fine anatomy
Sharp precise dissection
Reduction of operating time
Reduced blood loss
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17. Choice of Mesh 1. Compound polypropylene
2. e PTFE expanded polytetrafluoroethylene
3. Mixtures of absorbable and permanent fibres woven together to minimise the foreign body reaction
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18. Here is the original team who came to our hospital to teach first procedure from Europe.
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You can see the hernia inflated laparoscopically and illuminated

19. Choice of Mesh
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20. This is the mesh being cut and rolled up to be inserted into the laparoscope and a key hole cut out to go around the stoma
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21. Pre op Post op This is the wound after surgery 1st day posy op
Key hole ports some have 2 or 3 this one had 5
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22. Pre op
Post op
Note scar this patient has from previous localised suturing of a para stomal hernia repair, That hernia came back in less than 6 months
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23. Pre op Post op One week post op Suture marks healed click
This lady had a very large hernia and was surgically classed obese

24. Pre op
Post op
This was the 78year old lady whose hernia was causing great discomfort and had previous admission for obstruction
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Most of the patients who underwent surgery had suffered from constant discomfort, “dragging2 pain disruption to bowel function and several in danger of intermittent obstruction and / or strangulation
This photo is 2 days post op

25. Patients Jan 2005 Female 76 years Colostomy 3 days
Female years Urostomy days
Female years Colostomy days
Female years Ileostomy days
Male years Ileostomy days
Male years Ileostomy days
Female years Colostomy days
Some of these patients would not previously been considered for open surgery due to their medical risk assessment and expected morbidity
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26. Patients reviewed 3 monthly 2 recurrences - further repair
Follow Up
Patients reviewed 3 monthly
- 25 months
No mesh related bowel erosion, fistulisation or adhesion formation observed
2 recurrences - further repair
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27. Summary Faster recovery of bowel function Less morbidity
Shorter length of hospital stay
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28. Conclusion Parastomal herniae are common
Associated with high morbidity
Laparoscopic repair decreases post-operative pain
Faster recovery
Decreased overall morbidity
Greater patient satisfaction
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29. This is one of the first patients who went to the local press expressing his gratitude and delighted with the success of his hernia repair
Before I finish
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