There are different options for open surgical parastomal hernia repair. A surgeon will select one based on the hernia’s location, severity, and the type of ostomy surgery previously performed (colostomy, ileostomy or urostomy). A CT scan and MRI may be used to diagnose a possible course of action. Once the surgeon opens and examines the defect first hand, the final decision is made.
Repair Around the Stoma
The easiest method is to repair the defect around the stoma. The surgeon makes an incision alongside the stoma, empties the contents of the parastomal hernia back into the abdominal wall and sutures (closes) the defect. This technique was once considered the “gold standard” as it was the least complex of all other surgical alternatives. However it lost favor during the last two decades because of high recurrence rates. Furthermore, for Sugarbaker (2014) “In most paraostomy hernias, direct re-approximation of fascia to close the defect is not possible” (1).
Repair with Polypropylene Mesh
A variant to the above technique involves placing a polypropylene mesh to cover the defect. Success rate is better, but placement of a mesh carries complications. In the short term, a seroma (pocket of clear serous fluid) and hematomas may arise. In the long term, chronic infections (from the stoma), contractions, displacements, fistulas and pain may be present. In addition, there may be inadequate mesh placement (too loose renders it ineffective and too tight impedes normal bowel movement), and erosion into the intestine forcing an eventual mesh extraction.
Repair via Abdominal Incision
Another technique requires re-opening the abdominal incision used to do the original procedure, inserting the mesh through the abdomen and wrapping it around the stoma. Manipulating from inside the abdominal cavity allows for more accurate mesh placement and reduction of infections.
Parastomal Hernia Repair: Redoing Ostomy Surgery
The most radical technique is to withdraw the stoma and relocate it somewhere else on the abdomen. The parastomal defect is eliminated with sutures and then covered with mesh to prevent any recurrences. The stoma is displaced, inserted through the rectus abdominis muscle (for better support and less chances of recurrence), and retracted out through the new incision (made just big enough to channel the stoma). This approach is the very traumatic and is usually left for patients with large hernias that might also be experiencing situations like tightening or retraction of the stoma.
For Sugarbaker (1980) “Prosthetic mesh can be used in a sublay position for repair of the fascial defect without the problems that bacterial contamination of the operative field presents” (2). Also, in this procedure, “The mucosal bud is not disturbed, and this facilitates rapid return to normal intestinal function. The hernia defect is closed with prosthetic material and approximately 10 cm of bowel exiting from the ostomy tunnel is also covered by mesh” (3). This technique is known as the “Sugarbaker or Pocket repair” of a parastomal hernia. The method seems to be a leading one to repair parastomal hernias.
There are various methods available, and none is without difficulties and risks. The best advice is to take all precautions possible after the first hospital discharge, including wearing an ostomy support belt when prescribed by a physician.
(1) Sugarbaker, P (2014), American Society of Abdominal Surgeons, Paraostomy Hernias: Prosthetic Mesh Repair, Available online at: http://www.abdominalsurg.org/journal/2014/paraostomy-hernias-prosthetic-mesh-repair.html
(2) Sugarbaker, P (1980), Surgery, Gynecology & Obstetrics. 150:576-578, Prosthetic Mesh Repair of Large Hernias at the Site of Colonic Stomas.