parastomal hernia dr chan wai hei, arthur queen elizabth hospital

Parastomal herniaParastomal hernia

Dr Chan Wai Hei, ArthurQueen Elizabth Hospital

OverviewOverview

BackgroundBackground ClassificationClassification Risk factorsRisk factors Clinical presentation & Complications Clinical presentation & Complications

requiring surgical interventionrequiring surgical intervention ManagementManagement PreventionPrevention

DefinitionDefinition

A parastomal hernia (PSH) is a type of A parastomal hernia (PSH) is a type of incisional hernia that occurs at the site of incisional hernia that occurs at the site of stoma or immediately adjacent to the stoma or immediately adjacent to the stomastoma

The most common late complication of a The most common late complication of a permanent stomapermanent stoma

IncidenceIncidence

Variable incidence reported in literatureVariable incidence reported in literature Incidence increases with timeIncidence increases with time Most occur within 2 years of stoma Most occur within 2 years of stoma

formationformation Some believe that it is an inevitable Some believe that it is an inevitable

consequence of stoma formationconsequence of stoma formation

IncidenceIncidence

[Pilgrim CH, McIntyre R, Bailey M. Prospective audit of parastomal hernia: prevalence and associated comorbidities. Dis Colon Rectum 2010;53:71-6]

IncidenceIncidence

Literature review by Carne et al. Literature review by Carne et al. 1.8-28.3% in end ileostomies1.8-28.3% in end ileostomies 0-6.2% in loop ileostomies0-6.2% in loop ileostomies 4.0-48.1% in end colostomies4.0-48.1% in end colostomies 0-30.8% in loop colostomies0-30.8% in loop colostomies

[Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784-93]

ClassificationClassification

TraditionalTraditional RadiologicalRadiological

Classification - TraditionalClassification - Traditional 4 subtypes4 subtypes 1) Subcutaneous1) Subcutaneous

most common typemost common type the herniation enters into the subcutaneous fat alongside the the herniation enters into the subcutaneous fat alongside the

stomastoma 2) Interstitial2) Interstitial

the herniation extrudes alongside the bowel for stoma, then the herniation extrudes alongside the bowel for stoma, then burrows into one of the intermuscular planesburrows into one of the intermuscular planes

3) Peristomal3) Peristomal the stomal bowel is prolapsed and loops of bowel and/or the stomal bowel is prolapsed and loops of bowel and/or

omentum enter the hernia space produced between the layers of omentum enter the hernia space produced between the layers of prolapsed bowelprolapsed bowel

4) Intrastomal4) Intrastomal enters the plane between the merging and the everted part of enters the plane between the merging and the everted part of

bowelbowel usually occurs in the spout type of stoma – e.g. ileostomyusually occurs in the spout type of stoma – e.g. ileostomy

[Devlin HB. Peristomal hernia. In: Operative Surgery Volume 1: Alimentary Tract and Abdominal Wall, 4th ed, Dudley H (Ed), Butterworths, London 1983. p.441.]

Classification - RadiologicalClassification - Radiological

[Moreno-matias J, Serra-aracil X, Darnell-martin A et-al. The prevalence of parastomal hernia after formation of an end colostomy. A new clinico-radiological classification. Colorectal Dis. 2009;11 (2): 173-7]

type Ia type Ib type II type III

Risk factorsRisk factors

Patient-relatedPatient-related Surgery-relatedSurgery-related

Patient-related risk factorsPatient-related risk factors

AgeAge Obesity (>30kg/m2) and waist circumference Obesity (>30kg/m2) and waist circumference

(>100cm)(>100cm) Poor nutritional statusPoor nutritional status Increased intraabdominal pressure (COAD, Increased intraabdominal pressure (COAD,

constipation, BPH, ascites, etc)constipation, BPH, ascites, etc) Connective tissue disordersConnective tissue disorders Immunosuppressive drugs (e.g. corticosteroids)Immunosuppressive drugs (e.g. corticosteroids) Other disease predispose to wound infection Other disease predispose to wound infection

(e.g. DM)(e.g. DM) Other underlying diseases (e.g. IBD, malignancy)Other underlying diseases (e.g. IBD, malignancy)

Surgery-related risk factorsSurgery-related risk factors Emergency construction of stomaEmergency construction of stoma Stoma lateral to rectus muscleStoma lateral to rectus muscle Diameter of trephine Diameter of trephine

defect >3cm was found to be associated with a higher incidence defect >3cm was found to be associated with a higher incidence of herniation, independent of stoma typeof herniation, independent of stoma type

currently few data to base advice about the appropriate size of currently few data to base advice about the appropriate size of abd wall openingabd wall opening

suggestions of not more than 2.5cm had been madesuggestions of not more than 2.5cm had been made smallest opening that allows the creation of a viable stoma smallest opening that allows the creation of a viable stoma

without ischaemia appears to be the best guidewithout ischaemia appears to be the best guide Closure of lateral spaceClosure of lateral space Stoma fixation to fasciaStoma fixation to fascia Intraperitoneal or extraperitoneal approachIntraperitoneal or extraperitoneal approach

Clinical presentationClinical presentation

Vary from asymptomatic to life-threatening Vary from asymptomatic to life-threatening strangulationstrangulation

Typically – bulge at the site of or adjacent to the Typically – bulge at the site of or adjacent to the stoma, with or without painstoma, with or without pain

Mild abd discomfort, intermittent colic, distention, Mild abd discomfort, intermittent colic, distention, nausea & vomiting, diarrhoea, constipation and nausea & vomiting, diarrhoea, constipation and a reducible hernia a reducible hernia

Physical examination – on lying down and Physical examination – on lying down and standing with valsalvastanding with valsalva

Digital examination enables the fascial aperture Digital examination enables the fascial aperture and parastomal tissues to be assessedand parastomal tissues to be assessed

Complications requiring surgeryComplications requiring surgery

Literature reported a range of 11%-70%Literature reported a range of 11%-70% Local data: ~32% require surgical interventionLocal data: ~32% require surgical intervention Urgent surgery for strangulation of an irreducible herniaUrgent surgery for strangulation of an irreducible hernia Following signs & symptoms can be repaired electivelyFollowing signs & symptoms can be repaired electively

increasing sizeincreasing size intermitted bowel obstructionsintermitted bowel obstructions chronic abdominal pain related to PSHchronic abdominal pain related to PSH ill-fitting appliance and leakageill-fitting appliance and leakage peristomal skin breakdownperistomal skin breakdown other stoma complicationsother stoma complications

ManagementManagement

ConservativeConservative SurgerySurgery

Closure of stomaClosure of stoma Direct fascial repairDirect fascial repair RelocationRelocation Mesh repairMesh repair

Different locationDifferent location Lap vs openLap vs open Laparoscopic techniquesLaparoscopic techniques

PreventionPrevention

Direct fascial repairDirect fascial repair

Reduce size of hernia defect by reapproximating the Reduce size of hernia defect by reapproximating the fascial edges of trephine with suturesfascial edges of trephine with sutures

AdvantageAdvantage simple techniquesimple technique avoids laparotomyavoids laparotomy low complication rate in elective operationlow complication rate in elective operation may have a role when there is a strong desire to avoid mesh or may have a role when there is a strong desire to avoid mesh or

more major surgerymore major surgery

DisadvantageDisadvantage excessive tension and subsequent failure in large fascial defectexcessive tension and subsequent failure in large fascial defect high recurrence rate – reported in various literature to be 46-high recurrence rate – reported in various literature to be 46-

100%100%

RelocationRelocation This approach avoided because the new stoma at new site is This approach avoided because the new stoma at new site is

associated with the same high risk of hernia formationassociated with the same high risk of hernia formation Some authors reported a lower recurrence rate after relocation to Some authors reported a lower recurrence rate after relocation to

other side of abdominal wall than relocation on the same side of other side of abdominal wall than relocation on the same side of abdomenabdomen

AdvantageAdvantage useful if the current stoma position unsatisfactoryuseful if the current stoma position unsatisfactory can be done with or without laparotomycan be done with or without laparotomy lower recurrence rate than direct fascial repairlower recurrence rate than direct fascial repair

DisadvantageDisadvantage local recurrence rate reported in literature ~36.3% (range up to 76.2%)local recurrence rate reported in literature ~36.3% (range up to 76.2%) not feasible if patient has multiple previous scarsnot feasible if patient has multiple previous scars risk of incisional hernia at the site of the original stoma or midline woundrisk of incisional hernia at the site of the original stoma or midline wound more risk of morbidity if require laparotomymore risk of morbidity if require laparotomy

[Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784-93]

Mesh repairMesh repair

Overall recurrence rates after mesh repair Overall recurrence rates after mesh repair vary between 6.9-17.8% (depending on vary between 6.9-17.8% (depending on technique and placement of mesh)technique and placement of mesh)

Overall mesh infection rate 2.4%Overall mesh infection rate 2.4% Risk of mesh infection did not differ Risk of mesh infection did not differ

between mesh techniquesbetween mesh techniques

[HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a systematic review of literature. Ann Surg 255(4): 685-695]

Different anatomical locations of Different anatomical locations of meshmesh

[Israelsson LA. Parastomal hernias. Surg Clin North Am. 2008;88:113-125]

Onlay techniqueOnlay technique First described by Rosin and Bonardi in 1977First described by Rosin and Bonardi in 1977 Mesh placed subcutaneously and fixed onto the anterior rectus Mesh placed subcutaneously and fixed onto the anterior rectus

aponeurosisaponeurosis Prefascial plane was entered through a lateral parastomal incisionPrefascial plane was entered through a lateral parastomal incision After reduction of hernia sac, the fascial opening was narrowed with After reduction of hernia sac, the fascial opening was narrowed with

sutures and mesh was placed to reinforce the suture repairsutures and mesh was placed to reinforce the suture repair Advantage:Advantage:

more straight forward surgical technique involving a meshmore straight forward surgical technique involving a mesh avoids intra-abdominal dissectionavoids intra-abdominal dissection

DisadvantageDisadvantage associated with higher risk of contamination & sepsis than sublay associated with higher risk of contamination & sepsis than sublay

techniquetechnique extensive dissection of subcutaneous tissue extensive dissection of subcutaneous tissue predisposes to haematoma / seroma formationpredisposes to haematoma / seroma formation undermining is a risk for ischaemic injury to skin => impair wound undermining is a risk for ischaemic injury to skin => impair wound

healinghealing intraabdominal pressure may lead to detachment of mesh resulting in intraabdominal pressure may lead to detachment of mesh resulting in

recurrencerecurrence

Onlay techniqueOnlay technique


Sublay techniqueSublay technique Mesh placed between rectus muscle and posterior Mesh placed between rectus muscle and posterior

sheathsheath Fewer studies evaluating this method of mesh placementFewer studies evaluating this method of mesh placement Small series with relatively short follow up (most <12mo)Small series with relatively short follow up (most <12mo) Overall recurrence rate 6.9%Overall recurrence rate 6.9% AdvantageAdvantage

intraabdominal pressure does not dislocate the mesh from repairintraabdominal pressure does not dislocate the mesh from repair no direct contact with bowelno direct contact with bowel

DisadvantageDisadvantage more technically challenging than onlay techniquemore technically challenging than onlay technique

Inlay tecniqueInlay tecnique

Mesh cut to size of abdominal wall defect, Mesh cut to size of abdominal wall defect, placed within fascial defect and sutured to placed within fascial defect and sutured to fascial edgesfascial edges

Abandoned because of high failure ratesAbandoned because of high failure rates

Intraperitoneal onlay position Intraperitoneal onlay position (IPOM)(IPOM)

Mesh placed intraabdominally on the Mesh placed intraabdominally on the peritoneumperitoneum

2 techniques – keyhole or Sugarbaker2 techniques – keyhole or Sugarbaker

Keyhole technique Sugarbaker technique


Sugarbaker techniqueSugarbaker technique Sugarbaker first described his technique in 1980Sugarbaker first described his technique in 1980 Technique:Technique:

trephine opening is covered with an intraperitoneally placed mesh via a trephine opening is covered with an intraperitoneally placed mesh via a laparotomy and sutured to fascial edgelaparotomy and sutured to fascial edge

bowel is lateralized passing from hernia sac between the abdominal wall bowel is lateralized passing from hernia sac between the abdominal wall and mesh into the peritoneal cavityand mesh into the peritoneal cavity

later modified to provide at least 5cm overlap of mesh and adjacent later modified to provide at least 5cm overlap of mesh and adjacent fasciafascia

AdvantageAdvantage generous mesh overlapgenerous mesh overlap flap valve effect created able to withstand increased intraabdominal flap valve effect created able to withstand increased intraabdominal

pressurepressure DisadvantageDisadvantage

mesh related complicationsmesh related complications dense adhesions causing intestinal obstruction requiring laparotomydense adhesions causing intestinal obstruction requiring laparotomy bowel erosion & fistula formationbowel erosion & fistula formation

Main application of these techniques is in laparoscopic repairMain application of these techniques is in laparoscopic repair

IPOMIPOM


Laparscopic techniquesLaparscopic techniques Key-hole vs modified sugarbaker vs sandwich technique Key-hole vs modified sugarbaker vs sandwich technique Potential advantagesPotential advantages

minimal additional injury to abdominal wall which is already at risk of minimal additional injury to abdominal wall which is already at risk of herniationherniation

better view of defect allowing more precise repair and reinforcement better view of defect allowing more precise repair and reinforcement with a meshwith a mesh

concomitant incisional hernia repairconcomitant incisional hernia repair faster postop recovery and decreased postop painfaster postop recovery and decreased postop pain

Sandwich techniqueSandwich technique

[Berger D, Bientzle M. Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair. A prospective, observational study with 344 patients. Hernia. 2009;13:167-172.]

Laparoscopic techniquesLaparoscopic techniques Key-hole vs modified sugarbaker vs sandwich technique Key-hole vs modified sugarbaker vs sandwich technique Recurrence rate:Recurrence rate:

Keyhole 34.6%Keyhole 34.6% Sugarbaker 11.6%Sugarbaker 11.6% Sandwich 2.1%Sandwich 2.1%

Conversion rate 3.6%Conversion rate 3.6% reasons: multiple dense adhesions, bowel injury, inaccessible abdomenreasons: multiple dense adhesions, bowel injury, inaccessible abdomen

Mesh infection rate 2.7%Mesh infection rate 2.7% Wound infection 3.3%Wound infection 3.3% Other complication rates 12.7%Other complication rates 12.7%

bowel injury 4.1% (15/363)bowel injury 4.1% (15/363) 5 repaired laparoscopically (1 hernia repair was postponed)5 repaired laparoscopically (1 hernia repair was postponed) 6 converted to open6 converted to open 4 were undetected (small bowel injury) during operation (3 required 4 were undetected (small bowel injury) during operation (3 required

reoperation, 1 resulted in multiorgan failure and death)reoperation, 1 resulted in multiorgan failure and death)

Lap vs Open techniquesLap vs Open techniques

Mesh techniques did not differ significantly in Mesh techniques did not differ significantly in terms of recurrenceterms of recurrence

Overall laparoscopic repair had no advantage Overall laparoscopic repair had no advantage over open repairover open repair


PreventionPrevention

High incidence of parastomal hernia High incidence of parastomal hernia together with unsatisfactory results of its together with unsatisfactory results of its repair and morbidity associated with repair and morbidity associated with operation lead to emphasis on preventionoperation lead to emphasis on prevention

Prevention strategiesPrevention strategies surgical techniquessurgical techniques prophylactic mesh insertionprophylactic mesh insertion

Surgical techniques in preventionSurgical techniques in prevention

Through or lateral rectus abdominisThrough or lateral rectus abdominis only retrospective studies found lower rate of PSH only retrospective studies found lower rate of PSH

with stomas formed through the rectus musclewith stomas formed through the rectus muscle nonetheless probably wise to bring out stoma nonetheless probably wise to bring out stoma

throught rectus abdominis ms as this is not throught rectus abdominis ms as this is not associated with any disadvantageassociated with any disadvantage

Fascial fixationFascial fixation Closure of lateral spaceClosure of lateral space Trephine sizeTrephine size Extraperitoneal route for stoma constructionExtraperitoneal route for stoma construction

Extraperitoneal route for permanent Extraperitoneal route for permanent colostomycolostomy

Few studies had shown that extraperitoneal approach can achieve lower Few studies had shown that extraperitoneal approach can achieve lower risk of herniation than transperitoneal routerisk of herniation than transperitoneal route

Potential disadvantagePotential disadvantage longer operative timelonger operative time may need mobilization of splenic flexure for extra lengthmay need mobilization of splenic flexure for extra length

Goligher first published the formation of extraperitoneal colostomy in 1958Goligher first published the formation of extraperitoneal colostomy in 1958 extraperitoneal route provides an oblique passage of bowel and eliminate the extraperitoneal route provides an oblique passage of bowel and eliminate the

lateral peritoneal space without using suturelateral peritoneal space without using suture attempt to reduce risk of postop small bowel obstruction due to internal herniation attempt to reduce risk of postop small bowel obstruction due to internal herniation

into lateral peritoneal space and reduce parastomal herniainto lateral peritoneal space and reduce parastomal hernia Since then, subsequent studies have been published with inconsistent Since then, subsequent studies have been published with inconsistent

resultsresults Only 2 retrospective studies found extraperitoneal colostomy construction Only 2 retrospective studies found extraperitoneal colostomy construction

was associated with a lower rate of parastomal herniation than was associated with a lower rate of parastomal herniation than intraperitoneal routeintraperitoneal route most studies were observational retrospective studies with small numbers of most studies were observational retrospective studies with small numbers of

patients undergoing extraperitoneal colostomy and follow up period was not patients undergoing extraperitoneal colostomy and follow up period was not mentionedmentioned

Studies of highter quality, including RCTS with larger no. of patients are Studies of highter quality, including RCTS with larger no. of patients are neededneeded

Prophylactic mesh insertionProphylactic mesh insertion Bayer and colleagues first described mesh insertion at Bayer and colleagues first described mesh insertion at

the time of primary stoma formation in 1986the time of primary stoma formation in 1986 Since then many observational studies confirmed the Since then many observational studies confirmed the

safety and effectiveness of prophylactic mesh insertion safety and effectiveness of prophylactic mesh insertion with low morbiditywith low morbidity

Three RCTs (2008-2009) have shown that prophylactic Three RCTs (2008-2009) have shown that prophylactic mesh in sublay position is associated with reduction in mesh in sublay position is associated with reduction in parastomal hernia when compared with standard stoma parastomal hernia when compared with standard stoma formationformation

Systematic review including the three RCTs found a Systematic review including the three RCTs found a statistically significant difference in the incidence of PSH statistically significant difference in the incidence of PSH in the mesh gp 12.5% and in the no-mesh gp 53%, but in the mesh gp 12.5% and in the no-mesh gp 53%, but no difference in morbidityno difference in morbidity

[Shabbir J, Chaudhary BN, Dawson R. A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation. Colorectal Dis 2012;14(8):931-6.]

RCTsRCTs

StudyStudy Patient Patient typestypes

No. of No. of patientpatient

ssType of meshType of mesh

Operative Operative techniqutechniqu

ee

Serra Serra AracArac

ililelectiveelective

Mesh 27, Mesh 27, no mesh no mesh

2727

Ultrapro (polypropylene + Ultrapro (polypropylene + polygelcaprone 25)polygelcaprone 25) SublaySublay

JanesJaneselective & elective &

emergeemergencyncy


2727

Vypro (polypropylene + polyglactin Vypro (polypropylene + polyglactin 910)910) SublaySublay

HammoHammondnd electiveelective


1010

Permacol (porcine derived Permacol (porcine derived crosslinked collagen implant)crosslinked collagen implant) SublaySublay

RCTs (cont)RCTs (cont)Loss to

follow up

StudyRandomi

zationBlindin

gEvaluation of

herniaFollow up /

monthsMesh No mesh

Serra Araci

l

sealed envelo

pe

assessor

Physical examination + CT abdomen

Median 29 (range 13-49)

0 0

Janesnot mentio

ned

assessor

Physical examination

only

Mean 65.2 (range 57-83)

6/27 at 12mo, 6/21 between 1-5yrs

1/27 before 12mo,

5/26 between 1-5yrs

Hammond

sealed envelo

pedouble

Physical examination +

stoma site USG

Median 6.5 (range 1-12)

0 0

RCTs (cont)RCTs (cont)

ParastomParastomal al

herniaherniaInfectionInfection

StudyStudy MeshMesh No meshNo mesh MeshMesh No meshNo meshMesh Mesh

complicaticomplicationsons

Serra Serra AraciAraci

ll

6/27 6/27 (22.2%(22.2%

))

12/27 12/27 (44.4%)(44.4%)

1/27 1/27 (3.7%)(3.7%)

1/27 1/27 (3.7%)(3.7%) 00

JanesJanes 2/15 2/15 (13%)(13%)

17/21 17/21 (81%)(81%) 00 00 00

HammoHammondnd 0/10 (0%)0/10 (0%) 3/10 3/10

(30%)(30%) 00 00 00

ConclusionConclusion

Concerning repairConcerning repair Mesh repair result in lower recurrence rateMesh repair result in lower recurrence rate Mesh techniques did not differ significantly in terms of Mesh techniques did not differ significantly in terms of

recurrence or morbidityrecurrence or morbidity Low overall rate of mesh infection and comparable for Low overall rate of mesh infection and comparable for

each mesh repaireach mesh repair Overall laparoscopic repair had no advantage over Overall laparoscopic repair had no advantage over

open repairopen repair Concerning preventionConcerning prevention

Meticulous surgical techniqueMeticulous surgical technique Adequately powered RCTs is still needed before Adequately powered RCTs is still needed before

recommendation of prophylactic mesh insertionrecommendation of prophylactic mesh insertion

DiscussionDiscussion

parastomal hernia dr chan wai hei, arthur queen elizabth hospital

Documents

site of stoma

viable stoma

permanent stoma slide

spout type of stoma

years of stoma formation

fascia stoma fixation

rectus muscle stoma

type of incisional hernia