Management of the Parastomal Hernia

A Park MD FRCS FACSA Park MD FRCS FACS

University Of MarylandUniversity Of Maryland

Baltimore, MDBaltimore, MD

Overview:

• Some Background – definitions, demographicsSome Background – definitions, demographics

• Pathophysiology & mechanisms of formationPathophysiology & mechanisms of formation

• Clinical presentation Clinical presentation

• Management & Techniques of repairManagement & Techniques of repair

• How well are we doing?How well are we doing?

• Role of prophylaxis?Role of prophylaxis?

Defining Terms – Let’s Be Clear:

A parastomal hernia is an incisional hernia A parastomal hernia is an incisional hernia related to an abdominal wall stoma (Carne related to an abdominal wall stoma (Carne 2003)2003)

……or even more broadly…or even more broadly…Any palpable defect or bulge adjacent to the Any palpable defect or bulge adjacent to the

stoma detected when the pt is supine with stoma detected when the pt is supine with legs elevated or while…straining when the legs elevated or while…straining when the pt is erect (Israelsson 2008)pt is erect (Israelsson 2008)

Devlin’s Classification of PH:

• HHelpful conceptually but of limited use clinical elpful conceptually but of limited use clinical studiesstudies

• 4 types, difficult to distinguish in clinically:4 types, difficult to distinguish in clinically:

i) subcutaneous i) subcutaneous

ii) interstitial ii) interstitial

iii) perstomal iii) perstomal

iv) intrastomaliv) intrastomal

Parastomal Hernias: Incidence

• 5% to 50% depending on definition & 5% to 50% depending on definition & means of detectionmeans of detection

• Higher rates more accurate?!Higher rates more accurate?!

• Colostomy Colostomy > ileostomy? Evidence limited> ileostomy? Evidence limited

• Lower with loops since shorter duration of Lower with loops since shorter duration of stoma stoma

Factors in Formation of Parastomal Hernias:

• General pt factors (as with VH): obesity, General pt factors (as with VH): obesity, malnutrition, COPD, malnutrition, COPD, age, wound infection age, wound infection

• Trephine size (?!):Trephine size (?!):

- 1 vs 2 fingers (Babcock)- 1 vs 2 fingers (Babcock)

- 1.5 cm (colon) vs 2 cm (ileum)- 1.5 cm (colon) vs 2 cm (ileum)

- - ⅔⅔ width of “crushed” intestine width of “crushed” intestine (Nguyen)(Nguyen)

Stoma Location & PH Formation:

• Never through laparotomy incision! Never through laparotomy incision! (infection, dehiscence, hernia)(infection, dehiscence, hernia)

• Historically through umbilicus when Historically through umbilicus when paramedian incision usedparamedian incision used

• Through rectus muscle vs lateral R.A Through rectus muscle vs lateral R.A

- limited evidence , no RCT data (2 of 6 - limited evidence , no RCT data (2 of 6 retrospective studies suggest some benefit)retrospective studies suggest some benefit)

• Pre op siting - no hernia advantage Pre op siting - no hernia advantage although more convenient & comfortable!although more convenient & comfortable!

PH:Clinical Presentation

• Most asymptomaticMost asymptomatic

• Mild to life threatening (strangulation)Mild to life threatening (strangulation)

• Often parastomal discomfort, int SBOOften parastomal discomfort, int SBO

• Difficulty with stoma appliance – skin Difficulty with stoma appliance – skin irritation, soilage irritation, soilage

• Psychological issues- more difficult to Psychological issues- more difficult to conceal stoma , smell etcconceal stoma , smell etc

Surgical Management of PH:

• Local Suture Repair (50-100% recurrence)Local Suture Repair (50-100% recurrence)

• Relocation of Stoma (36% recur BJS’03)Relocation of Stoma (36% recur BJS’03)

• Mesh RepairMesh Repair

- Inlay vs Onlay vs IPOM (Sub/Underlay)- Inlay vs Onlay vs IPOM (Sub/Underlay)

- Open vs Lap - Open vs Lap

Stoma Relocation

• Should be to contralateral sideShould be to contralateral side

- different quad same side… poor outcomes- different quad same side… poor outcomes

• Suture repair (only) of original site- 26% Suture repair (only) of original site- 26% recurrencerecurrence

• Risk of recurrence at new site same as Risk of recurrence at new site same as original(24-86%)even more if 2original(24-86%)even more if 2ndnd relocation relocation

PH: Mesh Repair/Positioning

• Inlay-no role ,recurrence too highInlay-no role ,recurrence too high

• Onlay- on Anterior aponeurosisOnlay- on Anterior aponeurosis

- concern re:infection ++- concern re:infection ++

- Intra abd pressure can displace mesh- Intra abd pressure can displace mesh

- min. data (recur?10%) rarely done- min. data (recur?10%) rarely done

• Sublay or IPOM , preferred by mostSublay or IPOM , preferred by most

- slit mesh vs “Sugarbaker”- slit mesh vs “Sugarbaker”

PH: Open Mesh repair Results(Carne ’03, Israelsson ’08)

• No prospective studies (let alone RCTs)No prospective studies (let alone RCTs)

• Data paltry, low recur. Short f/u (?)Data paltry, low recur. Short f/u (?)

• Infection rates low …although…Infection rates low …although…

• Mesh related complications can be highMesh related complications can be high

• Presented opportunity for Lap approachPresented opportunity for Lap approach

Rubin et al , Arch Surg 1994

• 68 parastomal repairs (55 patients)68 parastomal repairs (55 patients)

• f/u median 31 monthsf/u median 31 months

• Local (fascial) repair- 36 (53%)Local (fascial) repair- 36 (53%)

• Stoma Relocation - 25 (37%)Stoma Relocation - 25 (37%)

• Mesh Repair (mostly onlay) - 7 (10%)Mesh Repair (mostly onlay) - 7 (10%)

Rubin (cont.)

• 63% overall recurrence63% overall recurrence

• Local repair -76%Local repair -76%

• Stoma Relocation- 33% (52% got incisional Stoma Relocation- 33% (52% got incisional hernia)hernia)

• Mesh repair - 30%Mesh repair - 30%

Berger et al (Dis Colon Rectum ‘07)

• Retrospective study 1999-2006Retrospective study 1999-2006

• 66pts ( 22 recur hernias)- no conversions66pts ( 22 recur hernias)- no conversions

• ““Sugarbaker” & slit double mesh techniqueSugarbaker” & slit double mesh technique

• Median 24 mo f/u - 12% recurrenceMedian 24 mo f/u - 12% recurrence

• 3 major infections with mesh removal3 major infections with mesh removal

Mancini et al (Surg Endosc ’07)

• Multi-institute consecutive series 2001-2005Multi-institute consecutive series 2001-2005

• 25 pts (6 recurrent hernias)- no conversions25 pts (6 recurrent hernias)- no conversions

• Largely “Modified Sugarbaker”Largely “Modified Sugarbaker”

• Median f/u 19 mos. 4% recurrenceMedian f/u 19 mos. 4% recurrence

• 23% morbidity ( infectious,ileus,pulmonary)23% morbidity ( infectious,ileus,pulmonary)

Prevention of Parastomals(Janes, Israelsson et al BJS 2004)

Prospective Randomize Trial:Prospective Randomize Trial:

• Pts undergoing colostomy w/wo sublay meshPts undergoing colostomy w/wo sublay mesh

( light weight ,partially absorbable) 2001-2003( light weight ,partially absorbable) 2001-2003

• 54 pts entered(27/27) - periop morbidity same54 pts entered(27/27) - periop morbidity same

• At 12mos f/u: 18 no mesh – 8 recurrencesAt 12mos f/u: 18 no mesh – 8 recurrences

16 with mesh – 0 recurrences16 with mesh – 0 recurrences

• Study discontinued although f/u continuesStudy discontinued although f/u continues

Conclusions

• Parastomal hernia remain a common Parastomal hernia remain a common sequela of stoma formationsequela of stoma formation

• (Mercifully) many are asymptomatic (Mercifully) many are asymptomatic requiring no treatmentrequiring no treatment

• Surgical repair remains a challenge with Surgical repair remains a challenge with suboptimal outctomessuboptimal outctomes

• Mesh repair (underlay) shows most promiseMesh repair (underlay) shows most promise

• Must strongly consider prophylactic meshMust strongly consider prophylactic mesh