PARASTOMAL
HERNIAS
By Julia Thompson RN Dip Ned BA (Psych) Grad Dip
(Adv Clin Nsg) FCN (NSW) Sigma Theta Tau
CNC Stomal Therapy. Westmead Hospital NSW and
Lesley Jack RN RM CNS
Stomal Therapy. Westmead Hospital NSW
ABSTRACT
Parastomal hernia occurs when intestine protrudes through
the fascial defect around a stoma and into the subcutaneous
tissue. This paper looks at the literature in relation to
factors contributing to hernia development, the incidence,
the effects and the common treatments for parastomal hernias.
INTRODUCTION
Herniation around a stoma is the commonest late complication
of enterostome. (11) In 1980 Hughes referred to this as
"an unsolved stoma problem", and we propose that
it remains an unsolved problem in 1994. This paper will
review some of the established facts and raise some of the
still-unanswered questions.
Our
interest in hernias arose from our contact with several
patients whose hernias were causing them considerable concern
and affecting their quality of life. Either our conservative
measures had failed, or the patients were unwilling to try
them because they were so adamant that they wanted the hernia
surgically removed. Yet the surgeons were reluctant to operate
because they believed that the chances of success were low.
Of
the 594 new stomas created at Westmead Hospital between
February 1990 and December 1993, there were approximately
equal numbers of colostomies and ileostomies, but far fewer
urinary stomas. In all, 29 stomas required attention for
parastomal hernias: 20 colostomies (one transverse loop,
19 end colostomies), seven loop ileostomies, one ileal conduit
and one colonic conduit. This may not seem many, but these
were only the people who actually returned for help; we
do not know the real incidence.
A
parastomal hernia is caused by a gap between the intestinal
segment forming the stoma and the surrounding tissue (Fig
1). The bowel protrudes through the defect in the fascia,
resulting in a bulge at the base of the stoma. It may be
partially or fully circumferential. If the opening is small
the hernia is limited (parastomal), but often all the tissue
surrounding the stoma thins out (peristomal). (13) The protrusion
is accentuated when intra-abdominal pressure rises (e.g.
during coughing or sneezing. It may be reducible (e.g. when
the individual lies down); however, sometimes it is not.
FACTORS
CONTRIBUTING TO PARASTOMAL HERNIA DEVELOPMENT
The development of parastomal hernias is multifactorial.
One assumes that a major factor must be the 'weakness' (hole)
in the abdominal wall. However, although every ostomate
has this hole, they do not all develop a noticeable hernia.
Since this is a specialised form of incisional hernia, it
is precipitated by the same factors which lead to other
types of incisional hernias. These include chronic cough,
obesity, malnutrition, disorders of the urinary system and
anything else which causes increased intra-abdominal pressure.
Some
technical factors in stoma construction are believed to
predispose the patient to hernia development. These include
making the stoma in the main incision; (6) making the opening
in the muscle too large, and not bringing the stoma through
the rectus abdominus muscle. Sjodahl, Anderberg and Bolin
(11) found stomas through the rectus had a 2.9% incidence
of hernias but those lateral to the rectus had a 21.6% incidence.
This highly significant difference (p=0.0004, Chi squared
test) indicates that enterostomy should be constructed through
the rectus obdominus muscle, not lateral to it. They also
investigated the different incidence between ileostomy (2.2%)
and sigmoidostomy (8.9%) and found that it was not statistically
significant. However, others have made much of this difference
in incidence between stoma types.
Hulten
(6) proposed that it was due to the difference age groups
having colostomy as compared with ileostomy surgery. However,
Oritiz et al (7) took biopsies of rectus muscle at laparotomy
and performed morphometric studies which demonstrated no
significant difference between the two age groups (43.5
+ 17.5 years and 64.8 + 12.9 years). They concluded that
weakness of muscle wall due to increased age does not explain
the difference in prevalence of parastomal hernias between
colostomy and ileostomy.
INCIDENCE
The condition is certainly common, and increases with time
after surgery. Most occur during the first 2 years after
stoma formation, but some arise during the same hospitalisation
in which the stoma was constructed. (8) The reported incidence
of the problem varies greatly for several reasons. Many
studies do not specify the length of follow-up, so this
confuses the issue. (9) Another confounding aspect is that
some studies only count those hernias which need treatment,
whereas others include all (von Smitten et al, 1986). There
are also variations according to type of enterostomy. Pearl
(8) gives a table which illustrates the variation in reported
incidences. Goligher (1984) proposed that "a colostomy
is an unnatural protrusion through the abdominal wall and
some degree of herniation may be inevitable."
Other
estimates of incidence vary from 1-50%, but Pearl (8) puts
10% as a realistic estimate, noting that only 10-20% of
these need repair. According to Hughes (5) and Winkler (13)
the incidence is higher in loop colostomies, which they
note are often temporary or palliative. The incidence seems
to be lower following ileostomy and urinary diversion, with
Hulten (6) and Ortiz et al (7) reporting 3-10% and Devlin
(1983) reporting 5-10%.
Parastomal
hernia is obviously a common problem. But how big a problem
is it? This depends on the size of the hernia, on the individual
who has it and on how that person interprets their situation.
EFFECTS
OF PARASTOMAL HERNIAS
A
parastomal hernia may cause a range of psychological and
physical symptoms. To the onlooker it may just be a 'lump',
and 'unsightly bulge'. To the nurse or doctor it represents
a protrusion through a weakened muscle. But to the individual
concerned, its appearance may evoke their worst fears…of
a recurrence of their disease! Or it may be an embarrassment,
causing them to retreat from normal social activities.
CASE
A : Annie, a 72-year-old woman, underwent extensive surgery
for ovarian cancer. She was repulsed by the sight of her
open wounds and stoma, and covered her head with her nightgown
whenever they were dressed. Eventually she watched the stoma
care. Weeks passed before she was fit to walk, and when
she finally stood in the bathroom and looked at her abdomen
to learn to participate in stoma care, she was devastated
by what she saw…a lump - the very thing that had caused
her to go to the doctor in the first place!
CASE
B : Katie, a 50-year-old woman, had a temporary sigmoid
colostomy to divert faeces from a repaired recto-vaginal
fistula. She had a history of obesity, had lost approximately
30kgs some years prior to the ostomy surgery and was desperate
not to regain weight. She developed a moderate-sized parastomal
hernia about 2 months post-operatively. About the time she
was due to return to work someone, believing her to be pregnant,
asked her when the baby was due. She was so embarrassed
and upset that she refused to return to work or even to
socialise with her friends until the stoma was closed some
14 months after the original surgery, and would not give
permission for a photograph to be taken.
Other
effects include instability of the abdominal wall and a
strange feeling, "as if everything is falling out."
This can later give way to abdominal aching and discomfort,
and even intermittent intestinal obstruction. Strangulation
of the contents of the hernia may necessitate bowel resection,
(3,4) although Winkler (13) comments that this is uncommon
in large peristomal hernias because the sac is so large.
Difficulty
may arise during defecation. Appliances may not fit properly
due to the altered contour. Because the contents of the
hernial sac protrude when the person stands, but then recede
when they are recumbent, this causes the skin alternately
stretch and relax, disrupting the seal on the appliance
and leading to leakages and excoriation. This problem is
worse in those with ileostomies and urostomies because of
the nature of the effluent.
Interestingly,
there are occasions when stomas are easier to manage after
a hernia occurs because it corrects a previous indentation
which hindered appliance fixation.
When
irrigating is the usual method of colostomy management there
may be poor return, thought to be due to a siphon effect,
as described by Winkler (13).
DESCRIPTION
OF THE HERNIA
The hernial sac is lined with peritoneum and covered by
a thin layer of scar tissue. As the protrusion increases,
the subcutaneous fat thins out so that finally only a delicate
covering is left. In extreme cases pressure ulceration may
perforate, resulting in a fistula. The hernial sac may contain
loops of small bowel, omentum, prestomal loops of colon
and even transverse colon. The sac may become very large
to strangulation is less likely, but the muscular defect
may remain relatively small, in which case, theoretically,
the possibility for surgical correction is good. (2)
EXTERNALLY
The hernia starts as a low, round protrusion, usually with
the stoma in the middle. But in the course of time, with
enlargement and loosening of the skin, the sac descends
and the stoma may be difficult for the individual to see.
This can also make appliance management difficult. A hernia
may be complicated by loosening of the mesenteric pedicle
and lengthening of the mesentery within the peritoneal cavity,
which gives rise to prolapse. Loop ostomies are more likely
to be affected, but end ostomies may also have this complication.
TREATMENT
Many people do not seek treatment if the hernia is small,
and in people with a temporary stoma it is self-limiting
because the defect will be repaired during stoma closure.
Tretbar
(12) comments that in the older age group, who tend to have
more weight in their abdomen, there are advantages in resiting
a stoma above the umbilicus, where the rectus muscle is
usually thicker and stronger than below the umbilicus, the
there is less transmitted pressure to stretch the tissues
through which the stoma protrudes.
Although
local repair sounds easier because there is no need for
a laparotomy, the procedure may be technically difficult,
requiring wide undermining and careful dissection which
sometimes leads to post-operative fluid collections and
secondary infections, particularly when prosthetic mesh
is used.(5)
A
technique for hernia repair using Marlex mesh is outlined
by Rosin and Bonardi, (10) and also successfully used and
reported on by Abdu.(1) An eliptical incision dissects the
colostomy from the skin and down through subcutaneous tissue
to the fascia. The hernial sac is opened and the stoma clamped
to avoid spillage. The hernial sac is dissected free, opened
and reduced. The peritoneum is closed with chromic catgut.
The fascia is approximated with interrupted, non-absorbably
sutures. Redundant colon is removed. Marlex is tailored
to cover the area of the hernia and dissection, with the
end of the colon passing through a hole in the Marlex. The
Marlex is sutured to the fascia. The wound is irrigated
and a drain inserted before closure of the subcutaneous
tissues and skin. The stoma is refashioned. Dry dressings
are applied for 24 hours then an appliance is fitted. Antibiotics
are administered for 3 days, then the haemovac is removed.
Attention to aseptic technique is critical, since infection
in Marlex is devastating.
Bayer,
Kyzer and Chaimoff (2) propose a technique whereby the colostomy
is strengthened with Marlex (polypropylene) mesh at the
time of the original operation, in order to prevent subsequent
herniation. In their technique, a ring of Marlex with four
crosswise prolongations is sutured to the fascia. They reported
a series of 43 persons, with no hernia or prolapse up to
4 years later.
CONCLUSION
This paper has presented some ideas about the development,
incidence, effects and treatment of parastomal hernias.
But there are still unanswered questions. What is the actual
incidence? Apart from pre-operative siting and good surgical
technique, are there any other measures a surgeon can take
to reduce the incidence of hernias? Should stomal therapists
be encouraging more people to wear support binders or corsets
as a preventive measure? Should corsets have a hole in them
for the appliance, or is this merely mimicking the original
problem? Are there other conservative measures available?
Because
parastomal hernias are common and have the potential to
severely reduce quality of life, they are a subject worthy
of careful consideration by those caring for persons with
a stoma.
Reference
1.
Abdu RA (1982) Repair of paracolostomy hernia with Marlex
mesh,
DisColon Rectum 25:529-531.
2.
Bayer I, Kyzer S and Chaimoff C (1986) A new approach to
Primary strengthening of colostomy with Marlex mesh to Prevent
paracolostomy hernia,
Surgery, Gynaecology and Obstetrics 163: 579-580
3.
Cuthbertson A, Collins J (1977) Strangulated para-ileostomy
Hernia,
Aust NZJ Surg 47: 86-87.
4.
Daniell S (1981) Strangulated small bowel hernia with a
Prolapsed colostomy stoma,
JR Soc Med 74: 687-688.
5.
Hughes E (1980) Unsolved stoma problems, Paper presented
at the 10th annual conference of the Australian Association
Of Stomal Therapy Nurses, Perth 28-3-80.
6.
Hulten L (1984) Prevention and management of paracolostomy
hernia, Paper presented at the conference of the World Congress
of Enterostomal Therapists, South Africa.
7.
Ortiz H, Gracia F, Sara M, de Miguel M, Garrido J and Perez
I (1991) Is colostomy hernia related to age?
Journal of the World Council of Enterostomal Therapists
11 (2): 19.
8.
Pearl RK (1989) Parastomal hernias,
World Journal of Surgery 13: 569-572.
9.
Porter JA, Salvati EP, Rubin RJ, Eisenstat TE (1989) Complications
of colostomies.
Dis Colon Rectum 32 (44): 299-302.
10.
Rosin JD and Bonardi RA (1977) Paracolostomy hernia repair
with Marlex mesh.
Dis Colon Rectum 20 (4): 299-302.
11.
Sjodahl R, Anderberg B and Bolin T (1988) Parastomal hernia
in relation to site of the abdominal wall,
Br J Surg 75: 339-341.
12.
Tretbar LL (1988) Insoluble stomal complications: the need
For surgical revision, Conference Proceedings from the
WCET Congress, Norway.
13.
Winkler R. (1986) Stoma Therapy: An Atlas and Guide for
Intestinal Stomas.
Georg Thieme Verlag Stuttgart, New York: 55.
Further
reading
Doberneck Rc (1991) Revision and closure of the colostomy,
Surg Clin North Am 7(1):193.
Ortiz
H, Sara M, de Miguel M, Marti J, Petri M, Lopez E and Tegido
M (1993) Does the frequency of Colostomy hernia depend on
the colostomy location in the Abdominal wall? Journal
of the World Council of Enterostomal Therapists 13(2):
13-14.
Santora
TA, Roslyn JM (1993) Incisional Hernia,
Surg Clin North Am 73(3):557-570.
