Parastomal Hernias

Gwen B. Turnbull, RN, BS

A s soon as a stoma is constructed, a potential site of weakness in the abdominal wall is instantly produced. Parastomal hernia occurs when weakness in the abdominal wall is sufficient to permit abdominal contents, usually the intestine, to protrude through the fascial defect around the stoma and into the subcutaneous tissue, creating a bulge on the abdomen. Parastomal herniation occurs in approximately 30% of all stomas1 and is more common in colostomies than in ileostomies and urostomies.

Peristomal herniation has been attributed to many causes: 1) placement of the stoma outside the rectus sheath, 2) an oversized defect created in the abdominal wall through which the stoma protrudes, 3) increased intra-abdominal pressure, 4) location of the stoma in a midline incision, 5) wound infection at the mucocutaneous border, or 6) poor abdominal muscle tone due to aging and weight gain or loss.2 The progress of a parastomal hernia is often gradual as the area next to the stoma stretches and becomes weaker over time. Every strain (coughing, laughing) or other increase in intra-abdominal pressure (with heavy lifting or strenuous abdominal exercise) causes the area around the stoma to bulge and/or the entire stoma to protrude as it is pushed forward by the intestine behind it.

An analysis of the United Ostomy Association's data registry of 16,470 patients3 found that hernia was the most common complication for patients with stomas located outside the rectus sheath. A small study in Europe found that the placement of the stoma on the abdomen did not influence the rate of para-colostomy hernia.4 Traditional practice, however, seems to support stomal placement through the rectus sheath as an optimal measure to prevent parastomal hernia formation.

As time passes, the size of a hernia will likely increase. These hernias are rarely painful but can be uncomfortable and cause embarrassment if they are large enough to be seen through clothing. Because the uneven abdominal contours around the stoma created by the hernia fluctuate as the hernia alternately protrudes and reduces in response to body movement or changes in intra-abdominal pressure, parastomal hernias can cause serious management problems that result in leakage, skin irritation, and shortened wear time.

Over the years, many surgical approaches to hernia repair have been implemented with the goal of making the abdominal wall tissue fit snugly around the stoma, leaving no weaknesses. Even though this may seem to be the simplest and most logical intervention, it is not always successful. Today, three techniques are currently used for repairing a parastomal hernia:1 1) localized fascial repair, 2) localized fascial repair with mesh, and 3) relocation of the stoma. Surgical options for treating primary large symptomatic parastomal hernias include local repair with mesh implantation and stomal relocation. Stomal relocation is a major surgery with laparotomy and necessitates moving the stoma to another site on the abdomen and repairing the hernia at the old site. Recurrent hernias are best treated by local repair with mesh implantation. The use of mesh over and beyond the weakened area reinforces the weakened muscle structure and spreads the mechanical load over a larger area. Controversy exists regarding which procedure should be used at what point in the progression of the hernia. Some clinicians believe that for first presentation parastomal hernias relocation should be the treatment and that recurrent hernias should be repaired with implantation of mesh.1

Because of the high recurrence rates, small hernias that are not symptomatic or hernias in patients who are not surgical candidates are best managed conservatively. Such management consists of observation, the use of a hernia support belt designed to fit around the pouch and provide support to the abdominal wall, and ongoing patient education. The support belt should be applied with the patient in a recumbent position while the hernia is reduced. By virtue of their rigidity, some convex products pose the potential for pressure-related skin or stomal damage for a patient with a parastomal hernia. They should, therefore, be used with caution. Patients may be better served with flexible, low profile, or newer flangeless pouching systems worn under the hernia support belt.

With quality of life such a pivotal issue in today's healthcare environment, serious consideration should be given to the management of parastomal hernias. Nurses caring for stoma patients should instruct not only at-risk patients (those with colostomies, poorly sited stomas, weight gain, or poor abdominal muscle tone) but also all stoma patients on proper steps they can take to prevent the development of and progressive enlargement of a parastomal hernia. A new generation of flangeless pouching systems may assist in reducing leakage and preventing skin irritation as well as improve patient comfort for patients with parastomal hernias.

The development of a parastomal hernia creates multiple quality-of-life issues for the patient and consumes valuable healthcare resources. Patient education plays a critical role in preventing the progression of a parastomal hernia and conservative management of a small asymptomatic one. - OWM

Comments

My hernia is large and often painful. I rarely am able to get the pouch attached securely because of the very bumpy surface of the hernia. Therefore, I leak frequently - sometimes 3 - 4 times a day. My WOC nurses have been unable to help me. And I am not a candidate for hernia repair. Any suggestions would be greatly appreciated.r

try getting flanges (banana shaped pads) which go either side of the stoma bag preventing leakage

Do you know the brand name of the product you are recommending? It sounds like something that might help me with my hernia that causes increasing problems.
'
Thank you.

They are called hydro frames

I was experiencing the same problems as you whilst at work which was very embarrassing as i am a Nurse having to change up to 4 times a day was getting me down.I tried many products however i have now found that the Salts Harmony Duo Drainable Pouches HDD1350 & Harmony Duo Standard Flanges Flexifit with Aloe Vera FHD1350 to be very successful.They seem to move with my hernia instead of working against it ,allowing my appliance to stay on for many hours. These numbers are for the Australian Stoma Scheme so i hope this information has helped you.

I, too, have developed a hernia at the stoma. It is high and uneven. I use the 2 inch tape supplied by my apparatus company and it stays quite well. I use the one piece pouch and clean sometimes 3 times a day but the basic pouch stays quite well with the tape. There is some itching sometimes. Although in very decent health, at 81 and a survivor of three different cancer surgeries over 2 years, I am a poor candidate for reattachment or surgery for the hernia. Since there is no pain, I guess I can put up with it. If you haven't tried the tape - Transpore - you might want to. Good Luck.

I HAVE A PARASTOMAL HERNIA THAT HAS SPREAD FROM THE STOMAL SITE (RIGHT OF CENTER AT THE WAIST LINE) AROUND ABOUT 5 INCHES TO THE RIGHT. THE STOMA ITSELF PROTRUDES ABOUT 2.5" WHEN UNOBSTRUCTED. I BUILT AN INSERT THAT GOES INSIDE OF THE APPLIANCE, THAT WORKS IN CONJUNCTION WITH A REINFORCED COLLAR THAT IS WORN ON THE OUTSIDE OF THE APPLIANCE. THIS TWO PIECE SYSTEM DOES A VERY GOOD JOB HOLDING THE HERNIATED STOMA FLAT WITHOUT PUTTING TOO MUCH PRESSURE ON THE TISSUE AROUND THE STOMA. I HAVE HAD NO PROBLEMS WITH PRESSURE SORES. THE SYSTEM ALSO INCREASED WEAR TIME OF THE DISPOSABLE APPLIANCES FROM HOURS TO DAYS. I AVERAGE A 4 DAY WEAR TIME. I USE A TWO PIECE CONVATEC SYSTEM THAT I UNCLIP NIGHTLY WHEN I SHOWER. I CLEAN THE INSERT BY SOAKING IT IN VINEGAR. I CLEAN AROUND THE STOMA WITH SOAP AND WATER WHILE IN THE SHOWER. I HAVE BEEN USING THIS SYSTEM NOW FOR ALMOST A YEAR WITH ONLY GOOD RESULTS.

This sounds really good. More info about what you are using would be useful.

I also have a parastomal hernia (second one and the stoma has been moved from my right side to my left side). However, due to a heart problem further surgery is not recommended. I would be grateful for any information on your insert and re-inforced collar (although to date I am not a fan of two piece appliances). I find getting clothes to fit around the hernia is difficult without getting ridiculously large fits so holding the hernia flat would be a great help.

I have been an ostimate for eight years now and not only am I experienceing a parastomal hernia but also an incisional hernia(s) also. My situation does involve pain, severe at times, depending on time of day and what I have been doing. Although I do not do any lifting or anything that would aggrevate it but it is there. Being in a horizontal position seems to ease it off but it takes time for this to occur. I am very likely a candidate for the surgery described. I am not able to work anymore due to that and the injury that occured during the complete colectomy as direct result of the surgery. Then I had a proctectomy in another Hospital by yes, another Surgeon and it all went very well, hard to get through but success, brilliantly done. But not the first surgery at all as it left me with on-going serious problems for the rest of my life. These problems are a serious matter and should not be taken lightly as they can as the text says get worse as we age, etc. and attention needs to paid to them. I know soon I must do something about my problems related to this posting. I can be reached at jmartin49@carolina.rr.com
Thanks for reading,
John

Just wondered if anyone has had surgery to repair 3 hernias, I have a permanent ileostomy with a parastomal hernia underneath which is both painful, uncomfortable and prevents bags staying on for very long, along with lots of night time leakage interupting my sleep. My surgeon is operating next week to repair all 3 hernias and move the ileostomy to god knows where but i am so miserable as i cannot even put my socks/tights on or my boots. Have already had 4 hernia repairs which have failed, any advice would be much appreciated and how long do you think i will be in hospital, many thanks, my e-mail address is vanessa43@vanessa43.karoo.co.uk

I have a hernia where my stoma use to be and it is to be repaired tomorrow, January 24, 2012.
It has now been a little over a year since my ostomey was reversed. I have had alot of burning and pain in the hernia area.

I underwent an abdominal perineal resection on 27/04/2010 and after recovery went back to work as an interstate truck driver. I drive a b-double which means I have to pull myself up into the cab to drive, I drive from Sydney to Melbourne and back approx. 3 times per week. I then have to open and close heavy vinyl curtains on the side of the trailers, lift gates on the side on the trailers, which are around 50kgs each - they are attached to the sides of the trailers but I do need to lift them in and out of sockets and guide them. I need to lean under the trailers to afix the straps and then wind them (like a winch). I returned to work doing all of this approximately 3 months post the above noted surgery. I have now, over time, developed a parastomal hernia which I was having some very worrying symptoms with and eventually, after my general practitioner become concerned as well, returned to my surgeon and underwent a parastomal hernia repair which, instead of being day/overnight surgery as I was advised it would have been ended up in hospital for 5 days. This, I was told, was the result of having strangulation of the hernia, removal of more bowel and reformation of the stoma, also told that they had to cut some stomach muscle, move to and then re-attach (there could have been more complications, I don't have a copy of the surgical report).

My question is: could/would these complications have been caused as a result of the type of work I do (as explained above) as an aggravation/exaserbation of the expected parastomal hernia and what are my chances of this type of aggravation/exaserbation of a parastomal hernia being caused again should I return to my employment as an interstate truck driver?

I had colorectal cancer necessitating removal of rectum and permanent colostomy on left side. I soon developed a parastomal hernia which was operated on a year ago but a few months later the hernia was back bigger than ever. I have now developed severe inflammation and pain in my lower back parallel with the hernia and wonder if the two are related. Surgeon thinks relocation is the only way forward but says same thing might happen on the right side. Anyone getting back pain with a PH. Regards, Ivan Gordon

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