Parastomal Repair: Open Techniques

Molly M. Ford

Charles B. Whitlow

BACKGROUND

Parastomal hernia is defined as a hernia in direct relation to an abdominal wall stoma (Fig. 49-1). Tangential forces on the circumference of the opening cause enlargement of the aperture in the abdominal wall around a stoma. Patients may be asymptomatic or describe symptoms such as a bulge, pain, or an obstruction.

Because of the nature of the necessary fascial defect and the aforementioned forces, parastomal hernia occurrence is high. Radiographically, it is found in up to 80% of patients. The clinical rate of parastomal hernia has been reported to range between 5% and 52%. The great variance reported has been attributed to the utilization of different definitions of hernia and a wide range of follow-up criteria for patients. The most durable repair of a parastomal hernia defect is with reversal of the ostomy; however, there are many scenarios in which a stoma is permanent.

INDICATIONS

Indications for parastomal hernia repair depend on the symptoms. Obstruction or incarceration with strangulation is an absolute indication, but relative indications for repair include difficulty with appliance management, pain, and cosmesis. Patient-specific risk factors for the development of parastomal hernias include obesity, weight gain after ostomy creation, advanced age, malnutrition, increased intra-abdominal pressure, immunosuppression, creation in an emergent setting, and wound infection. Other suggested factors include stoma placement outside of the rectus muscle and creation of an excessively large fascial opening.

FIGURE 49-1 True parastomal hernia.

Open techniques for parastomal hernia repair include direct local tissue repair, application of prosthetic material around the stoma at different levels upon or within the abdominal wall including both the keyhole and Sugarbaker repair, and relocation of the intestinal stoma with closure of the primary aperture. This chapter discusses these open surgical approaches.

Worth mentioning is the consideration of mesh use at the primary stoma creation. Data from a recent meta-analysis suggest that parastomal hernia occurrence is significantly reduced with prophylactic mesh from 50.3% to 24.4%.

PREOPERATIVE PLANNING

Once the patient has completed an appropriate preoperative medical clearance, consideration should be given to a bowel preparation if the patient has a colostomy. An appropriate broad-spectrum antibiotic should be administered intravenously, 1 hour before the incision. As with other abdominal operations, venous thrombosis prophylaxis is utilized. The consent form should include information concerning the potential use of prosthetic materials in the management of the repair, as well as a clear discussion of alternatives, and reasonable clinical expectations including the possibility of recurrence.

SURGERY

Under general anesthesia, the patient is placed in the supine position with the extremities appropriately padded. The utilization of an oral gastric tube and urinary bladder catheter are at the discretion of the surgeon.

Operative Technique

Direct Fascial Repair

An arched incision is made through the skin around the hernia site. With careful retraction, the hernia sac and scar tissue is excised and the contents are reduced. The edges of healthy fascia are then approximated with a series of interrupted, nonabsorbable sutures to reduce the opening to one fingerbreadth around the stoma. This technique has generally fallen out of favor because of higher recurrence rates reported to range between 50% and 100%.

Relocation of Stoma

Preoperative marking of a new stoma site in another abdominal quadrant is important, usually on the contralateral side. After skin preparation and patient positioning, the existing ostomy is carefully isolated from the abdominal wall, and the stomal lumen is sutured closed to prevent contamination of the field. Dissection commences at the mucocutaneous junction until encountering the hernia sac; the hernia is reduced and the hernia sac is excised. A small midline incision is utilized to enter the abdominal cavity for adhesiolysis and exposure to both the new and old sites. The new ostomy site is created and the bowel is carefully brought through the new fascial opening without rotation or compromise to lumen or blood supply. Once the stoma has been mobilized and is in the abdominal cavity, the remaining hernia site is repaired with interrupted fascial sutures. It may be desirable to place prosthetic material in the sublay position under the muscle and external to the peritoneum to ensure an adequate repair for large hernia defects. Finally, the abdominal wound is closed, and the new stoma is matured in a Brooke manner for an ileostomy, and in a Brooke or flush manner for a colostomy.

An alternative to the use of a midline wound is possible with large parastomal hernias. The initial incision is around the stoma to free the bowel from the skin and hernia sac. With this technique, the hernia defect is used to gain access to take down the abdominal wall adhesions and accomplish the necessary bowel mobilization. The new stomal site can also be created using the hernia opening and a midline incision is avoided. After delivery of the bowel through the new stomal opening, the hernia is repaired as described; ultimately, the stoma is matured (Fig. 49-2). As with primary repair, re-siting of the stoma carries a high rate of recurrence, and so is also not the favored technique. However, if the parastomal hernia defect is very large, this may be the only option.

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