Parastomal hernia (PSH) occurs after colorectal surgery that requires either an end ostomy or protective stoma after a resection, and the rate of PSH can be as high as 80%. Unfortunately, not only is PSH a common complication but it also significantly affects patients’ lives. Construction of colostomy or ileostomy at the time of any colorectal surgery can be as high as 50%. Over 120,000 new stomas are created each year in the United States and more than half of the patients with an ostomy will never have their stoma reversed. PSH results in an impingement of quality of life, high output, obstruction, prolapse, malnutrition, dehydration, parastomal skin disruption, and irritation. Patients may have different combinations of the aforementioned complications. The indications to repair PSH are the same regardless of the planned method of the repair, either by laparoscopy or open surgery.

Generally, the indications to operate on patients with PSH vary depending on the chronicity of PSH, severity of the condition, and the degree of disability and impairment. How aggressively a surgeon decides to approach the PSH will depend on the acuity of the hernia or the symptoms that arise from it. First, PSH can be divided into either acute or chronic, defined by the time elapsed from the original surgery. Acute PSH, especially the ones that occur within a few hours to days after the surgery, is usually due to technical error, and patients will most commonly present with obstruction, incarceration, or strangulation, where prompt surgical repair is usually indicated. Some authors believe that all patients will eventually have a PSH if they are followed up long enough; therefore, most patients who are evaluated for PSH will generally be under the chronic type of PSH. For chronic PSH, conservative management usually is effective for patients with mild to moderate symptoms. These measures including customized stoma support, skin protective sealants, stoma or abdominal support belt, and better utilization of wound care nursing services can effectively manage peristomal wound complications, decrease the leak because of better appliance management, and improve quality of life.

When conservative measures have failed to control the symptoms, surgery is indicated. The majority of patients who seek surgical consultation and undergo an operation have at least one episode of obstruction, chronic pain, or constant leakage. Operative therapy can also be offered on the basis of the patient’s psychosocial factors, poor cosmesis, and financial implication. Patients with PSH are more likely to have a worse quality of life compared to patients without PSH. These patients have been shown to have higher rates of apprehension secondary to appliance failure, needing to know where the nearest toilet is, higher financial burden to maintain the stoma-related apparatus, and social isolation resulting from the foul odor with frequent leak. Also, the financial implication from society as a whole cannot be overlooked because it has shown that patients with PSH will go on disability on account of the physical restriction that ultimately leads to decreased work productivity.

Even for chronic PSH, the severity of the condition will dictate how aggressively a surgeon should approach the problem. When patients present with high-grade obstruction, incarceration, perforation, or strangulation of bowel at the hernia site, prompt surgical repair will reduce perioperative surgical complication, morbidity, and mortality.

In general, indications for the laparoscopic approach heavily rely on the physician’s expertise. Laparoscopy usually yields better wound complication rate, faster recovery, and shorter hospital stay; however, it requires a trained surgeon, staff, equipment, and hospital to accommodate a laparoscopic
procedure. Provided that patients are able to tolerate general anesthesia, pneumoperitoneum, and the surgeon who is performing the procedure is adequately trained, a laparoscopic approach is typically best.

When patients meet one or more indications to have their PSH repaired, there are some contraindications for the laparoscopic approach that should be preoperatively considered.

There are several absolute contraindications of laparoscopy. First, patients need to be hemodynamically stable because the procedure cannot be completed safely without full anesthesia support. If the patient is experiencing severe septic shock secondary to the underlying condition that is not responding to medical therapy preoperatively, laparoscopy should be abandoned. Even if the patient is stable enough to be induced and laparoscopy is attempted, it is advisable for the surgeon to abort the technique and convert it to open technique if patient’s hemodynamic status changes after the induction.

Another contraindication is an uncorrectable coagulopathy. When the patient has medical conditions such as liver failure, Coumadin toxicity in the setting of an emergency, disseminated intravascular coagulation, or the patient has been taking irreversible anticoagulants, laparoscopy is contraindicated. Severe bleeding will interfere with adequate visualization of the operative field, which is a key component of a laparoscopic procedure.

Severe uncorrectable hypercapnia greater than 50 torr secondary to the patient’s underlying medical condition is an absolute contraindication because laparoscopy will inevitably raise the CO₂ level with insufflation. Although there are other gases that are available like argon or helium, the operating room (OR) or the hospital may not have those particular gases and those gases have their own set of problems such as high costs and flammability. Hypercapnia can be exacerbated by the pneumoperitoneum, which can result in a detrimental effect on the patient such as severe hemodynamic instability or arrhythmia.

The surgeon should be adequately trained and comfortable with the laparoscopic technique and the OR should be set up to accommodate the procedure with all the necessary components of basic laparoscopic surgery. Equipping the staff and OR with appropriate skills and tools provides the best outcome possible for the patient when laparoscopic surgery is offered.

Relative contraindications to laparoscopic PSH repair include multiple previous abdominal surgeries, suspected severe peritonitis, significant amount of bowel distention, and a tense abdominal wall. A previous midline abdominal incision should certainly raise concern when a surgeon is planning to perform laparoscopic surgery. During the preoperative visit, information such as when previous surgeries took place, the type of surgeries, and the number of interventions the patient had before he/she comes to your office should be accurately acquired. The laparoscopic approach may not be ideal for patients who had a recent open surgery within 6 weeks because of the large amount of expected dense adhesions.

Severe peritonitis, tense abdominal wall, and/or bowel distention may prevent an adequate surgical field because of limited pneumoperitoneum. Although these are not absolute contraindications, it is prudent to use these factors as relative contraindications when deciding to perform PSH repair laparoscopically.