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Parastomal hernia repair

Derek Fawcett

A parastomal hernia after ileal conduit formation is probably more frequent

than many urologists acknowledge. The hernia tends to occur at the

superolateral quadrant (9–12 o’clock position) of the stoma site in the right

iliac fossa. The mesentery normally lies at the 2–3 o’clock position of the

stoma, the superolateral quadrant representing an area of little resistance

where the abdominal content can easily herniate. The indications for surgery

include pain, cosmesis and risk of bowel obstruction or strangulation.

The lateral approach described here obviates the need for laparotomy and

stomal relocation, and allows continued use of the usual stoma appliance as

there is no peristomal incision. The dissection stays medial onto the external

oblique fascia. Extra care is needed in managing the very large and difficult

hernia so as to avoid devascularising the conduit.

The procedure should be covered with intravenous antibiotics, continued

for three doses after surgery. The patient should be placed in the supine

position and urine temporarily diverted from the wound by inserting a Foley

catheter into the conduit. The stoma in turn should be protected from the

wound by a gauze swab and drape.

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Figure 10.1 The incision was made lateral to the stoma.

Open Urology 19

A lateral incision is made about 10 cm from the stoma through the skin

into the subcutaneous tissue, well lateral to the stomahesive skin marks

(Figure 10.1). The extent of the hernia defect is delineated and the hernia sac

carefully preserved (Figure 10.2a). After extraperitoneal reduction of the her-

nia content, the defect is closed with interrupted non-absorbable sutures.

Alternatively, the sac can be opened (Figure 10.2b) and the content reduced

into the peritoneal cavity before the defect is closed with interrupted sutures.

The closed defect is then reinforced with a prosthetic mesh (Prolene, Ethicon,

UK), tailored to cover the lateral aspect (6–12 o’clock position) of the stoma

(Figure  10.3). The mesh is secured by interrupted non-absorbable sutures

onto the external oblique fascia. A drain is left around the mesh before wound

closure (Figure 10.4).

Without using a mesh repair the hernia recurrence rate is much higher. As

the lateral approach obviates the need for laparotomy and stomal relocation,

Figure 10.2 (a,b) Identification and opening of the hernia sac.

(a)

(b)

20 Top Tips in Urology

it enhances a quick return of bowel function, early discharge and early

recovery.

The anatomical landmarks and surgical principles described here can also

be of value when contemplating laparoscopic hernia parastomal repair.

Figure 10.3 The mesh used for reinforcing the hernia. The conduit lies medial to the

mesh.

Figure 10.4 After wound closure.