What is a Hernia/Stoma Hernia?
A hernia is a weakness or defect in the abdomen wall which allows abdominal contents (small bowel, colon, omentum etc.) to protrude through. The resulting bulge is initially noticeable only during periods of physical activity, but later on it becomes a persistent bulge, even simply standing.
Stomas pose an additional (major) problem:
During the creation of a stoma, the bowel is brought out through an artificially created split in the muscles of the abdominal wall. This is a balancing act between creating too tight a hole, which will result in impaired blood supply to the stoma, or too large a hole, so that the bowel will prolapse through the defect straight away. the latter explains how parastomal hernias occur, as with time, the hole through which the stoma goes through will enlarge and this will lead to a parastomal hernia. Indeed when patients with stomas are followed up long term, the vast majority will develop hernias.
Factors contributing to the development of a stoma hernia can be divided into technical factors (eg. too large a hole is made for the stoma at the initial operation or a stoma is made too lateral where the muscles are weaker or infection) and patient factors. The latter includes obesity, excessive coughing and straining. Like all hernias, once a stoma hernia develops it will get progressively larger and a significant number will require surgical correction.
Potential Complications of Parastomal Hernias
The symptoms of stoma hernias include the development of a bulge, pain, bowel obstruction and ill-fitting appliance. In fact one of the first signs of developing a stoma hernia is that the stoma bag becomes detached from the skin especially at night causing embarrassment, distress and relationship problems. The main reason why the stoma bag becomes detached especially at night is that with physical activities during the day the stoma hernia is at its largest. The appliance is usually applied then. However, when one goes to lie down in bed, some or most of the hernia contents reduce back inside the abdomen and this leaves floppy skin attached to the appliance which then becomes detached causing leakage.
Initially the stoma therapist can try different appliances or wearing a stoma belt but eventually the stoma becomes so large that the size differential between day and night times means that the appliance will become dislodged at night causing immense distress. This aspect of stoma hernia is often under appreciated.
With increasing size the stoma hernia will become increasingly noticeable through the clothes making the patients, who are already conscious of their predicament, even more embarrassed. Life threatening complications of stoma hernias including bowel obstruction and strangulation are thankfully rare and this leads to the general advice by the treating doctor that patients with stoma hernias should put up with them for as long as possible.
Ironically this is not the advice most surgeons would give to patients with all the other forms of hernias including ventral and incisional hernias. Generally patients are advised to get their hernias repaired, as long as they are fit enough for an operation, because hernias will always get bigger and will eventually cause problems including bowel obstruction and strangulation. So why then are the advices contradictory?
The answer lies in the fact that, up to now, there has been no effective surgical treatment. Currently, most stoma hernia repair operations involve a major abdominal laparotomy (long midline incision) with significant complications when the stoma hernia will usually recur. In addition there are significant risks of developing other hernias via the laparotomy incision, so-called incisional hernias. However, key hole hernia repair, which has revolutionised the repair of all the other types of hernias including inguinal, umbilical and ventral/incisional, is about to do the same for probably the most difficult of all hernias to repair, namely stoma hernias.
With this new development it is hoped that early surgical intervention will make the operation easier and will improve the quality of lives for patients who already have to live with a permanent stoma.
Resiting the stoma
This is a major operation which involves a laparotomy (usually going through the same incision as before) The surgeon takes down the stoma from inside, divide the adhesions, mobilising the limb of the stoma so that it can be placed on the opposite side of the abdomen as a new stoma. This morbid operation has numerous complications including wound infection, infection of the old stoma site, incisional hernia developing at the old stoma site, incisional hernia developing at the midline laparotomy and a very significant risk that another stoma will develop. All of these individual complications occur at rates of 10-50% which effectively means the risk of getting a complication is virtually 100%.
Stoma Hernia Repair
Primary suture repair: This should be obsolete as it is in the repair of all other forms of hernias. Essentially the surgeon attempts to use the weak tissues/muscle edges that cause the hernia in the first place to perform the repair with sutures. Invariable the sutures and/or tissues will tear resulting in a recurrence.
Mesh repair: The standard of care of modern hernia repair involves the use of a synthetic mesh prosthetic to reinforce the weakened tissues. Conventional stoma hernia repair involves the use of a slit mesh to allow the stoma to come through onto the skin. The mesh can be placed on the outside of the muscle, so-called onlay mesh repair, or under the muscle, so-called- underlay mesh repair. Both of these suffer from one major flaw in that a hole is made in the mesh to allow the stoma through and with time the hole with enlarge causing a recurrence of the stoma hernia. Again these operations involve a major laparotomy with attendant risks of infection, incisional hernia and the patients are in hospital for many days.
A slight improvement with the underlay mesh repair is that it can be performed with key hole surgery by competent laparoscopic hernia surgeons. However, as with conventional stoma underlay mesh repair, when a slit mesh is used the success is only marginally improved although the complications such as infection and incisional hernias are less.
The Sugarbaker stoma repair: In 1980, Sugarbaker recognised that the use of the slit mesh would cause recurrence via the slit, designed an operation where he placed broad piece of mesh over the stoma on the inside and then lateralise the limb of the stoma to lie against the lateral abdominal wall in a tunnel using the same mesh. He reported great success with this procedure which has since been replicated. However, this procedure involves a major laparotomy incision which entails significant risks enumerated above.
Laparoscopic stoma hernia repair using the modified Sugarbaker technique – 95% success rate
In essence this repair adopts exact same principles of a sound open (Sugarbaker) repair but with key hole surgery hence achieving great success while massively reducing the risks associated with conventional open surgery.
At this point I would like to pay tributes to the pioneers in laparoscopic hernia surgery who have revolutionised hernia repair. Some of these have been my mentors over the years. They are our US colleagues who, in their younger years, in the 90’s, were known in the medical circle as “young guns” who pushed the boundaries of laparoscopic surgery. Some of these “young guns” in their senior years have embarked and succeeded on the repair of perhaps the most difficult of all hernias, namely stoma hernias.
A recent publication by these surgeons have shown a success rate of 95% for laparoscopic stoma hernia repair with a non-slit mesh (in line with the best results for laparoscopic ventral/incisional hernia repair) with reduced hospital stay, early return to physical activities and reduced wound complications. Even though these surgeons are recognised as some of the best laparoscopic ventral/incisional hernia surgeons in the world such operations are still classified as major operations and major complications and even mortality have been reported.
For step-by-step guide to laparoscopic stoma hernia repair with modified Sugarbaker technique, please click here.
As this is a highly specialised area of surgery, patients are advised to do their own research (often local doctors and even general surgeons are not up to date with the latest advances in surgery) and to seek surgeons with the appropriate level of experience with laparoscopic hernia repair, and specifically laparoscopic ventral, incisional and stoma hernia repair.