Parastomal Hernia Repair

WHAT IS A PARASTOMAL HERNIA?

• A hernia occurs when the inside layers of the abdominal muscle have weakened, resulting in a bulge or tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a small balloon-like sac. This can allow a loop of intestine or abdominal tissue to push into the sac. The hernia can cause severe pain and other potentially serious problems that could require emergency surgery.
• A parastomal hernia is a special type of incisional hernia that occurs at the site of a stoma.  A stoma is when a portion of bowel is brought out the abdominal wall for elimination of stool or urine.
• The defects in parastomal hernias almost always contain a peritoneal sac with abdominal contents contained within the hernia. 
• It is common to have adhesions that fix abdominal contents within the hernia sac. This makes the hernia an incarcerated hernia.
• A hernia does not get better over time, nor will it go away by itself.
• Complications of parastomal hernias such as incarceration, strangulation and obstruction do occur.

HOW DO I KNOW IF I HAVE A PARASTOMAL HERNIA?

• Parastomal hernias can occur anywhere there is an abdominal stoma.
• It is usually easy to recognize an parastomal hernia. You may notice a bulge under the skin next to the stoma.  It may be difficult to get your stoma appliance to fit and function properly.  You may feel pain when you lift heavy objects, cough, strain, or during prolonged standing or sitting.
• The pain may be sharp and immediate or a dull ache that gets worse toward the end of the day.
• Severe, continuous pain, redness, and tenderness are signs that the incisional hernia may be entrapped or strangulated. These symptoms are cause for concern and immediate contact of your physician or surgeon.

WHAT CAUSES PARASTOMAL HERNIAS?

The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision or a weakness present from birth. Anyone with a stoma can develop an parastomal hernia at any age. A natural weakness or strain from heavy lifting, persistent coughing, difficulty with bowel movements or urination can cause the abdominal wall to weaken or separate.  At a stoma there is a natural weakness as the normal muscle and fascial layers have been opened to allow the stoma to come through the abdominal wall.  Smoking, obesity, malnutrition and pulmonary disease have been shown to be contributing factors.

WHAT PREPARATION IS REQUIRED?

• Most large parastomal hernia operations are require at least an overnight stay in the hospital.
• Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition.
• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
• It is recommended that you shower the night before or morning of the operation.
• If you have difficulties moving your bowels, an enema or similar preparation may be used after consulting with your surgeon.
• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
• Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
• Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home.

HOW IS THE PROCEDURE PERFORMED?

There are few options available for a patient who has a parastomal hernia. Most parastomal hernias require a surgical procedure at some point in time.  The open approach is done from the outside usually through the prior incision.  The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. If the defect is small, it can sometimes be closed with sutures.  Most parastomal hernias and certainly recurrent parastomal hernias are more complicated than this and require a complex repair with some type of mesh reinforcement.  These techniques requires a general anesthesia.  There are various types of mesh material both absorbable and permanent.  The type of material best suited for your hernia repair will be determined by your surgeon and whether or not there is any contamination in your case.  The laparoscopic approach requires several small incisions away from the stoma for the operative trocars.  A piece of mesh is placed within the abdomen through one of the trocar sites and is held in place with sutures through the muscle layers and surgical tacks around the edges of the mesh.

WHAT SHOULD I EXPECT AFTER SURGERY?

• Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake.
• Once you are awake and able to walk, you will be sent to your hospital room.
• With any hernia operation, you can expect some soreness mostly during the first 24 to 72 hours.
• You are encouraged to be up and about the day after surgery.
• You will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, light lifting, working and engaging in sexual intercourse.
• If you have drains in place, follow your surgeons instructions regarding returning to get the drains removed
• Call and schedule a follow-up appointment within 2 weeks after you operation.

WHAT COMPLICATIONS CAN OCCUR?

• Any operation may be associated with complications. The primary complications of any operation are bleeding and infection but these are uncommon with parastomal hernia repair.
• There is a slight risk of injury to the intestines, blood vessels and nerves.
• Difficulty urinating after surgery is not unusual and may rarely require a temporary tube into the urinary bladder for as long as one week.
• Any time an parasromal hernia is repaired it can come back or a new hernia can occur adjacent to the previous repair.  Your surgeon will help you decide if the risks of parastomal hernia repair are less than the risks of leaving the condition untreated.

WHEN TO CALL YOUR DOCTOR

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 101 degrees F (39 C)
• Bleeding
• Increasing abdominal or groin swelling
• Pain that is not relieved by your medications
• Persistent nausea or vomiting
• Inability to urinate
• Chills
• Persistent cough or shortness of breath
• Purulent drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger
• You are unable to eat or drink liquids                                    

Related Links and Resources

• UT Health Encyclopedia – Hernia
• If you need to go to the Emergency Room