“Intestinal stoma creation is one of the most common surgical procedures. 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
“Temporary diverting ileostomies (TDIs) are commonly formed by surgeons after anterior resection of mid- and low-rectal cancers to protect the distal coloanal anastomosis and to reduce the incidence of postoperative ileus and bowel obstruction. Despite being an effective preventative measure, the use of TDIs is associated with multiple stoma-related complications. One such complication is the development of incisional hernias at the ileostomy reversal site, which can occur in up to 48% of cases. Incisional hernias are problematic for patients because they can cause pain, lead to strangulation and may require operative repair. In addition to considerable morbidity for the patient, the significant financial burden is worth consideration.”2
Parastomal Hernias and Others-Incidence
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 concerning the incidence of parastomal and incisional hernias, but it is supposed to range 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%.
Regarding parastomal hernias solely, studies show a rather common occurrence 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 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%”3
“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.”5
“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?
There are some situations that 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); instances 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 conditions such as diabetes, and lung disease.
“Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma, i.e. a condition wherein abdominal contents, typically the bowel or greater omentum, protrude through abdominal integuments surrounded by the hernia sac at the location of the formed stoma. Significant problems result from the lack of a standard definition, even though as early as in 1973, Devlin suggested a classification based on 4 types of hernias: type I – integumentary (so-called true parastomal hernia); type II – subcutaneous; type III – intra-stomal; and type IV – pseudo pre-stoma.”7
“Five risk factors were found to be significant in the development of ileostomy-site hernias, namely, high BMI, lower age group, longer reversal time, open resection and a previous history of hernia. Two of these five risk factors (higher BMI and open resection) correlate well with previous larger studies evaluating the risk factors for incisional hernia formation following abdominal surgery. Approximately 15% of rectal cancer patients treated with anterior resection, TDI and subsequent ileostomy reversal develop incisional hernias at the ileostomy reversal site.”8
How to prevent a Parastomal or an Incisional Hernia?
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.”9
“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.”10
“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). This idea was first implemented by Bayer et al. in 1979 in which they reinforced the stoma site with Marlex mesh in 43 patients. None of these patients developed a PSH during the four-year follow-up period. Several subsequent observational studies found this practice to be safe and effective without an increased risk of infection or stoma complications. 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.”11
“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 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 prophylactic mesh augmentation (PMA) in patients at high risk for incisional hernias.”12
(1, 7) 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, 8) The incidence of incisional hernias following ileostomy reversal in colorectal cancer patients treated with anterior resection. Fazekas, B., Fazekas, B., Hendricks, J., Smart, N., & Arulampalam, T. The Annals of the Royal College of Surgeons of England. 2017. https://publishing.rcseng.ac.uk/doi/10.1308/rcsann.2016.0347
(3, 4, 11) 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
(5) 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
(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
(10) 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
(9, 12) 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