Parastomal Hernia Parastomal Hernia RepairRepair

C R KapadiaC R Kapadia

Airedale General HospitalAiredale General Hospital

Parastomal HerniaParastomal Hernia

““Some degree of herniation Some degree of herniation around a colostomy is so around a colostomy is so

common that this common that this complication may be complication may be

regarded as inevitable”regarded as inevitable”

GoligherGoligher

Parastomal HerniaParastomal Hernia

An Incisional Hernia related An Incisional Hernia related to an abdominal wall stoma.to an abdominal wall stoma.

Particularly noticeable on Particularly noticeable on tensing the abdominal wall tensing the abdominal wall muscles- coughing, muscles- coughing, sneezing, straining or sneezing, straining or standingstanding..

Para Stomal HerniaPara Stomal Hernia

Parastomal herniation is not Parastomal herniation is not uncommon and the uncommon and the management of a parastomal management of a parastomal hernia is a common clinical hernia is a common clinical dilemma. dilemma.

Once such a hernia is Once such a hernia is established, it is difficult to established, it is difficult to treat, and many operative treat, and many operative factors have been claimed to factors have been claimed to influence its occurrence and influence its occurrence and many techniques of repair many techniques of repair have been described. have been described.

[Carne, Robertson and Frizelle][Carne, Robertson and Frizelle]

Incidence of Parastomal Incidence of Parastomal HerniaHernia

0 – 48% depending on type of stoma 0 – 48% depending on type of stoma and length of follow upand length of follow up

[Carne, PWG; Robertson, GM; Frizelle, FA. 2003][Carne, PWG; Robertson, GM; Frizelle, FA. 2003]

20-25% Commoner in end colostomy20-25% Commoner in end colostomy[Devlin, 1982][Devlin, 1982]

67% transverse loop colostomy67% transverse loop colostomy[Nordstrum &Hulten, 1987][Nordstrum &Hulten, 1987]

Incidence of Parastomal Incidence of Parastomal HerniaHernia

50% Colostomy 50% Colostomy [Nugent, 1999][Nugent, 1999]

28% Ileostomy28% Ileostomy[Williams, 1990][Williams, 1990]

5-8% Urostomy5-8% Urostomy[Rubin & Bailey1993][Rubin & Bailey1993]

DiagnosisDiagnosis

HistoryHistory

Examination Examination - Standing- Standing- Lying- Lying

Valsalva manoeuvreValsalva manoeuvre

Digital examination of stomaDigital examination of stoma

CT ScanCT Scan

Classification Classification (Devlin)(Devlin)

InterstitialInterstitial

SubcutaneousSubcutaneous

IntrastomalIntrastomal

PeristomalPeristomal

Risk FactorsRisk Factors

IntrinsicIntrinsic

Age Age

ObesityObesity

Wound InfectionWound Infection

SmokingSmoking

ExtrinsicExtrinsic

Emergency SurgeryEmergency Surgery

Location of StomaLocation of Stoma

Previous repairPrevious repair

TreatmentTreatment

Restore continuity of the Restore continuity of the intestineintestine

Indications for Surgical Indications for Surgical RepairRepair

StrangulationStrangulation

ObstructionObstruction

Fistula formationFistula formation

IschaemiaIschaemia

PainPain

Body Image - patient expectationBody Image - patient expectation

Choice of Surgical Choice of Surgical ProceduresProcedures

1. Stoma Relocation1. Stoma Relocation

2. Local Tissue Repair2. Local Tissue Repair

3. Prosthetic Repair3. Prosthetic Repair - intraperitoneal- intraperitoneal

- - extraperitonealextraperitoneal

- fascial onlay- fascial onlay

Surgical RepairSurgical Repair

Increased infection ratesIncreased infection rates

Recurrence 39% Recurrence 39% [Reiger, [Reiger, 2004]2004]

Complications 57% Complications 57% [Hughes, 1999][Hughes, 1999]

Laparoscopic repair with mesh Laparoscopic repair with mesh 10% recurrence10% recurrence [Le Blanc, 2004][Le Blanc, 2004]

LaparoscopicLaparoscopic SurgerySurgery

Cost EffectivenessCost Effectiveness

Decreased:Decreased:

Chest infectionChest infectionWound infectionWound infectionAdhesion complicationsAdhesion complicationsEarlier recoveryEarlier recoveryShorter patient stayShorter patient stayBetter productivityBetter productivity

Advantages of LaparoscopyAdvantages of Laparoscopy

Direct magnified vision allowingDirect magnified vision allowingidentification of fine anatomyidentification of fine anatomy

Sharp precise dissectionSharp precise dissection

Reduction of operating timeReduction of operating time

Reduced blood lossReduced blood loss

Choice of MeshChoice of Mesh

1. Compound 1. Compound polypropylenepolypropylene

2. e PTFE 2. e PTFE expanded expanded

polytetrafluoroethylene polytetrafluoroethylene 3. Mixtures of absorbable 3. Mixtures of absorbable

and permanent fibres and permanent fibres woven together to woven together to minimise the foreign minimise the foreign body reactionbody reaction

Choice of MeshChoice of Mesh

Pre opPre op Post opPost op

Pre opPre op Post opPost op

Pre opPre op Post opPost op

Pre opPre op Post opPost op

Patients Jan 2005Patients Jan 2005

FemaleFemale 76 years Colostomy 3 days 76 years Colostomy 3 days

FemaleFemale 52 years 52 years ColostomyColostomy 5 days 5 days

MaleMale 68 years 68 years ColostomyColostomy 4 days 4 days

FemaleFemale 73 years Colostomy 73 years Colostomy 4 days 4 days

FemaleFemale 68 years 68 years UrostomyUrostomy 5 days 5 days

FemaleFemale 78 years 78 years ColostomyColostomy 6 days 6 days

FemaleFemale 68 years 68 years IleostomyIleostomy 4 days 4 days

MaleMale 58 years 58 years IleostomyIleostomy 5 days 5 days

MaleMale 49 years Ileostomy 49 years Ileostomy 4 days 4 days

FemaleFemale 65 years Colostomy 4 days 65 years Colostomy 4 days

Follow UpFollow Up

Patients reviewed 3 monthlyPatients reviewed 3 monthly

- 25 months- 25 months

No mesh related bowel erosion, No mesh related bowel erosion, fistulisation or adhesion formation fistulisation or adhesion formation

observedobserved

2 recurrences - further repair2 recurrences - further repair

SummarySummary

Faster recovery of bowel functionFaster recovery of bowel function

Less morbidityLess morbidity

Shorter length of hospital stayShorter length of hospital stay

ConclusionConclusion

Parastomal herniae are commonParastomal herniae are common

Associated with high morbidityAssociated with high morbidity

Laparoscopic repair decreases Laparoscopic repair decreases post-operative painpost-operative pain

Faster recoveryFaster recovery

Decreased overall morbidityDecreased overall morbidity

Greater patient satisfaction Greater patient satisfaction