“The most common long-term complication following stoma creation is a parastomal hernia, which according to some authors is practically unavoidable. Statistical differences of its occurrence are mainly due to patient observation time and evaluation criteria. Consequently, primary prevention methods such as placement of prosthetic mesh and newly developed minimally invasive methods of stoma creation are used. It seems that in the light of evidence-based medicine, the best way to treat parastomal hernia is the one that the surgeon undertaking therapy is the most experienced in and is suited to the individuality of each patient, his condition and comorbidities. As a general rule, reinforcing the abdominal wall with a prosthetic mesh is the treatment of choice, with a low rate of complications and relapses over a long period of time. The current trend is to use lightweight, large pore meshes.”1
An incisional hernia may develop after any surgical procedure requiring surgical incisions. A parastomal hernia surfaces around the stoma and may follow any surgery for colostomy, ileostomy, or urinary diversion. There is debate about incidence of parastomal and incisional hernias, but it ranges between 20-30% of total interventions. The success rate for surgical repair in both types of hernia is quite low as the recurrence rate stands close to 50%.
Incidence of Incisional Hernias
“Incisional hernia at the previous stoma site occurred in approximately one‐third of patients after stoma reversal. This seems an appropriate reflection of the true patient population experiencing incisional herniation, as this was a consecutive cohort of patients who had a stoma for a variety of reasons. Many patients wished to undergo surgical correction of the hernia. Higher BMI, stoma prolapse, parastomal hernia, hypertension and colostomy reversal in patients with an underlying malignant disease were identified as independent risk factors for the development of an incisional hernia.”2
Incidence of Parastomal Hernias
“Essentially, a parastomal hernia is an incisional hernia related to an abdominal wall stoma. […] In general surgical practice, the rate of parastomal hernia is probably between 30 and 50%. The rate of parastomal hernia is probably similar to an ileostomy and to a colostomy, although a higher rate has been suggested with the latter in some studies.”3
Studies show a rather common occurrence of parastomal hernias during the first years subsequent to ileostomy or colostomy surgery. The incidence of parastomal herniation is approximately up to 48% on end-colostomies, 31% on loop-colostomies, 40% on ileostomies, and 28% on loop-ileostomies.
“With regard to stoma type, colostomies traditionally have been thought to confer a higher risk of PSH (parastomal hernias) than ileostomies. However, there are conflicts in the literature. Overall, the rate of PSH for a loop colostomy and end colostomy ranges from 0 to 30.8% and 4.0 to 48.1%, respectively. The rate for a loop ileostomy and end ileostomy ranges from 0 to 6.2% and 1.8 to 28.3%, respectively. The likely explanation for the lower rates of PSH for loop ostomies is due to their reversal prior to the development of a PSH. This problem is not confined to gastrointestinal or general surgery because ostomy formation at the site of an ileal conduit is quite common. The rate of herniation at a urostomy site is similar to that of an end ileostomy with a range of 5 to 28%”4
“Parastomal hernias continue to be a common complication after stoma surgery. Their rate of incidence varies between 4% and 48%. Although most asymptomatic hernias are well tolerated and can be managed conservatively, approximately 30% of hernias require surgical intervention for symptoms that include bowel strangulation, obstruction, bleeding, parastomal pain, poorly fitting appliances, and leakage”6
What may cause a Parastomal or an Incisional Hernia?
Certain situations make a person susceptible to developing a hernia: surgeries that take intestine around and not through the rectus abdominus muscle (which helps to hold the stoma); circumstances that weaken the abdominal wall, such as obesity, malnutrition, corticosteroid use, wound infection, and age; undue intra-abdominal pressure from lifting objects or chronic coughing; and presence of chronic conditions such as diabetes, and lung disease.
Causes of Incisional Hernias
“Incisional hernias, also known as ventral hernias, are defined as the protrusion of intra-abdominal viscera through a defect in the abdominal wall caused by a previous operative intervention. The visceral contents are covered by a lining of peritoneum known as the hernia sac. As with other types of hernia, the sac is not reducible, whereas the contents may be.”7
Causes of Parastomal Hernias
“Development of parastomal herniation has been associated with patient and technical-related risk factors. Patient-related risk factors for parastomal hernia include female sex; age >60 years; obesity (waist circumference of >100 cm or body mass index of >25 kg/m2); smoking; comorbidities such as hypertension, chronic respiratory disease, and ascites; poor nutritional status; inflammatory bowel disease; immunosuppression; corticosteroid use; postoperative sepsis; concomitant incisional hernia; and increases in intra-abdominal pressure. Surgery or technique-specific factors that should be taken into consideration include emergency stoma placement, the type of stoma, surgical technique for ostomy construction, the diameter of the trephine, or size of the aperture in the abdominal wall, bringing the stoma out through the resection site, placement of prophylactic mesh, and position of the stoma. However, the exact pathogenesis of PSH formation remains unclear.”8
How to prevent a Parastomal or an Incisional Hernia?
“Hernia prevention can come in many forms, including decreased infection, less open surgery, patient ‘prehabilitation’, optimal suture technique, and mesh-reinforced closures. Prehabilitation relevant to preventing incisional hernias would include steps taken to optimize a patient’s wound healing, including control of diabetes, smoking cessation, weight loss, and good overall nutritional status. Several key stakeholders have been identified, including patients, hospitals, payers, industry, and providers.”9
In general, optimal surgical approach (you need a good surgeon), good physical condition, orderly life, and wearing ostomy support or hernia belt are major factors preempting incisional and parastomal hernias. “Surgeons should have a keen knowledge of the advantages and disadvantages of different incision types used for abdominal surgery. While many factors should be considered when choosing the incision type, formation of an incisional hernia should be part of the decision-making process.”10
Patients can prevent hernias by using appropriate garments while exercising. “There is some evidence that patients are less physically active after primary stoma formation. It is intuitive, however, that maintaining abdominal core musculature is beneficial for abdominal wall function and simple exercise programs are available that facilitate patient engagement and concordance. Most patients gain confidence from the use of support garments but they are not proven to stop the formation of PSHs with only observational studies to support their use in ostomates. Of note, a study of abdominal binders following epigastric or ventral hernia repairs demonstrated a subjective benefit but no significant difference in any other outcomes.”11
Certain studies have found a lower incidence of Parastomal Hernias is associated to the use of prophylactic mesh. “With such a high incidence of PSH and recent success with mesh repair, much attention has been given to prophylactic mesh placement at the time of primary stoma formation, especially for permanent colostomy after abdominoperineal resection (APR). […]A recent meta-analysis in 2012 that included three randomized controlled trials demonstrated a substantial difference in the incidence of PSH between controls and patients with prophylactic mesh. The incidence was 12.5% for those with mesh and 53% for controls with no difference in mesh-related morbidity. Studies have varied as to whether the prophylactic mesh was placed in an onlay, retromuscular, or intraperitoneal position.”12
“Incisional and parastomal hernias remain a conundrum for surgeons performing abdominal surgery. There are several evidence-based approaches that can help significantly reduce incisional hernia rates. Suturing techniques and the use of prophylactic mesh augmentation (PMA) will continue to evolve as more research is completed with the goal of eliminating incisional and parastomal hernias in the future. Despite significant advances in surgical techniques and understanding of abdominal wall anatomy and function, the rate of incisional hernias following laparotomy incision remains high. Due to this and the realization that long-term outcomes of repair of incisional hernias are suboptimal, there has been an increased emphasis on hernia prevention. The two main focuses related to hernia prevention have been suture techniques for laparotomy closures and the concept of PMA in patients at high risk for incisional hernias.”13
The incidence of parastomal and incisional hernias is highly correlated. It explains why prevention approaches for both are similar. Consult with a physician if you feel any bulges or discomfort around your stoma area.
(1) Parastomal hernia – current knowledge and treatment. Styliński, R., Alzubedi, A., & Rudzki, S. VideoSurgery And Other Miniinvasive Techniques. 2018. https://www.termedia.pl/Parastomal-hernia-current-knowledge-and-treatment,42,31466,0,1.html
(2) Incidence of and risk factors for stoma‐site incisional herniation after reversal. Amelung, F., De Guerre, L., Consten, E., Kist, J., Verheijen, P., Broeders, I., & Draaisma, W. BJS Open. 2018. https://onlinelibrary.wiley.com/doi/full/10.1002/bjs5.48
(3) Preventing and treating parastomal hernia. Israelsson, L. A. World journal of surgery, 29(8), 1086-1089. 2005.https://link.springer.com/chapter/10.1007/978-3-540-68988-1_36
(4, 5, 12) Parastomal Hernia: A Growing Problem with New Solutions. Aquina, C,. Iannuzzi, J., Probst, C,. Kelly, K., Noyes, K., Fleming, F., & Monson, J. Digestive Surgery. 2014. https://www.karger.com/Article/FullText/369279
(6) Laparoscopic repair of parastomal and incisional hernias with a modified Sugarbaker technique. Jeong, D., Park, M., Melich, G., Hur, H., Min, B., Baik, S., & Kim, N. Journal Of The Korean Surgical Society. 2013. https://synapse.koreamed.org/DOIx.php?id=10.4174/jkss.2013.84.6.371
(7) A GP primer on incisional hernia. Australian Journal of General Practice. Turner, R. C. 47(9), 621. 2018. https://www1.racgp.org.au/ajgp/2018/september/a-gp-primer-on-incisional-hernia
(8) Parastomal Hernia. Celik, Suleyman & Kocaay, Akin & Akyol, Cihangir. 2017. https://www.researchgate.net/publication/319365303_Parastomal_Hernia
(9) Contemporary concepts in hernia prevention: Selected proceedings from the 2017 International Symposium on Prevention of Incisional Hernias. Harris, H. W., Hope, W. H., Adrales, G., Andersen, D. K., Deerenberg, E. B., Diener, H., … & Gibeily, G. J. 2018. https://www.surgjournal.com/article/S0039-6060(18)30099-0/fulltext
(10, 13) Fundamentals of incisional hernia prevention. Heathcote, S., Williams, Z., Borden Hooks, W., & Hope, W. International Journal of Abdominal Wall and Hernia Surgery. 2018. http://www.herniasurgeryjournal.org/article.asp?issn=2589-8736;year=2018;volume=1;issue=1;spage=32;epage=36;aulast=Heathcote
(11) Prevention and treatment of parastomal hernia: a position statement on behalf of the Association of Coloproctology of Great Britain and Ireland. The Association of Coloproctology of Great Britain and Ireland. Colorectal Disease. 2018. https://onlinelibrary.wiley.com/doi/full/10.1111/codi.14249