Transcript Parastomal hernia

Parastomal hernia
Dr Chan Wai Hei, Arthur
Queen Elizabth Hospital
Overview
 Background
 Classification
 Risk factors
 Clinical presentation & Complications
requiring surgical intervention
 Management
 Prevention
Definition
 A parastomal hernia (PSH) is a type of
incisional hernia that occurs at the site of
stoma or immediately adjacent to the
stoma
 The most common late complication of a
permanent stoma
Incidence
 Variable incidence reported in literature
 Incidence increases with time
 Most occur within 2 years of stoma
formation
 Some believe that it is an inevitable
consequence of stoma formation
Incidence
[Pilgrim CH, McIntyre R, Bailey M. Prospective audit of parastomal hernia: prevalence and associated comorbidities. Dis Colon Rectum 2010;53:71-6]
Incidence
 Literature review by Carne et al.
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1.8-28.3% in end ileostomies
0-6.2% in loop ileostomies
4.0-48.1% in end colostomies
0-30.8% in loop colostomies
[Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784-93]
Classification
 Traditional
 Radiological
Classification - Traditional
 4 subtypes
 1) Subcutaneous
 most common type
 the herniation enters into the subcutaneous fat alongside the
stoma
 2) Interstitial
 the herniation extrudes alongside the bowel for stoma, then
burrows into one of the intermuscular planes
 3) Peristomal
 the stomal bowel is prolapsed and loops of bowel and/or
omentum enter the hernia space produced between the layers of
prolapsed bowel
 4) Intrastomal
 enters the plane between the merging and the everted part of
bowel
 usually occurs in the spout type of stoma – e.g. ileostomy
[Devlin HB. Peristomal hernia. In: Operative Surgery Volume 1: Alimentary Tract and Abdominal Wall, 4th ed, Dudley H (Ed), Butterworths, London 1983. p.441.]
Classification - Radiological
type Ia
type Ib
type II
type III
[Moreno-matias J, Serra-aracil X, Darnell-martin A et-al. The prevalence of parastomal hernia after formation of an end colostomy. A new clinico-radiological classification.
Colorectal Dis. 2009;11 (2): 173-7]
Risk factors
 Patient-related
 Surgery-related
Patient-related risk factors
 Age
 Obesity (>30kg/m2) and waist circumference
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(>100cm)
Poor nutritional status
Increased intraabdominal pressure (COAD,
constipation, BPH, ascites, etc)
Connective tissue disorders
Immunosuppressive drugs (e.g. corticosteroids)
Other disease predispose to wound infection
(e.g. DM)
Other underlying diseases (e.g. IBD, malignancy)
Surgery-related risk factors
 Emergency construction of stoma
 Stoma lateral to rectus muscle
 Diameter of trephine
 defect >3cm was found to be associated with a higher incidence
of herniation, independent of stoma type
 currently few data to base advice about the appropriate size of
abd wall opening
 suggestions of not more than 2.5cm had been made
 smallest opening that allows the creation of a viable stoma
without ischaemia appears to be the best guide
 Closure of lateral space
 Stoma fixation to fascia
 Intraperitoneal or extraperitoneal approach
Clinical presentation
 Vary from asymptomatic to life-threatening
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strangulation
Typically – bulge at the site of or adjacent to the
stoma, with or without pain
Mild abd discomfort, intermittent colic, distention,
nausea & vomiting, diarrhoea, constipation and
a reducible hernia
Physical examination – on lying down and
standing with valsalva
Digital examination enables the fascial aperture
and parastomal tissues to be assessed
Complications requiring surgery
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Literature reported a range of 11%-70%
Local data: ~32% require surgical intervention
Urgent surgery for strangulation of an irreducible hernia
Following signs & symptoms can be repaired electively
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increasing size
intermitted bowel obstructions
chronic abdominal pain related to PSH
ill-fitting appliance and leakage
peristomal skin breakdown
other stoma complications
Management
 Conservative
 Surgery
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Closure of stoma
Direct fascial repair
Relocation
Mesh repair
 Different location
 Lap vs open
 Laparoscopic techniques
 Prevention
Direct fascial repair
 Reduce size of hernia defect by reapproximating the
fascial edges of trephine with sutures
 Advantage
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simple technique
avoids laparotomy
low complication rate in elective operation
may have a role when there is a strong desire to avoid mesh or
more major surgery
 Disadvantage
 excessive tension and subsequent failure in large fascial defect
 high recurrence rate – reported in various literature to be 46100%
Relocation
 This approach avoided because the new stoma at new site is
associated with the same high risk of hernia formation
 Some authors reported a lower recurrence rate after relocation to
other side of abdominal wall than relocation on the same side of
abdomen
 Advantage
 useful if the current stoma position unsatisfactory
 can be done with or without laparotomy
 lower recurrence rate than direct fascial repair
 Disadvantage
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local recurrence rate reported in literature ~36.3% (range up to 76.2%)
not feasible if patient has multiple previous scars
risk of incisional hernia at the site of the original stoma or midline wound
more risk of morbidity if require laparotomy
[Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784-93]
Mesh repair
 Overall recurrence rates after mesh repair
vary between 6.9-17.8% (depending on
technique and placement of mesh)
 Overall mesh infection rate 2.4%
 Risk of mesh infection did not differ
between mesh techniques
[HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a
systematic review of literature. Ann Surg 255(4): 685-695]
Different anatomical locations of
mesh
[Israelsson LA. Parastomal hernias. Surg Clin
North Am. 2008;88:113-125]
Onlay technique
 First described by Rosin and Bonardi in 1977
 Mesh placed subcutaneously and fixed onto the anterior rectus
aponeurosis
 Prefascial plane was entered through a lateral parastomal incision
 After reduction of hernia sac, the fascial opening was narrowed with
sutures and mesh was placed to reinforce the suture repair
 Advantage:
 more straight forward surgical technique involving a mesh
 avoids intra-abdominal dissection
 Disadvantage
 associated with higher risk of contamination & sepsis than sublay
technique
 extensive dissection of subcutaneous tissue
 predisposes to haematoma / seroma formation
 undermining is a risk for ischaemic injury to skin => impair wound
healing
 intraabdominal pressure may lead to detachment of mesh resulting in
recurrence
Onlay technique
[HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a
systematic review of literature. Ann Surg 255(4): 685-695]
Sublay technique
 Mesh placed between rectus muscle and posterior
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sheath
Fewer studies evaluating this method of mesh placement
Small series with relatively short follow up (most <12mo)
Overall recurrence rate 6.9%
Advantage
 intraabdominal pressure does not dislocate the mesh from repair
 no direct contact with bowel
 Disadvantage
 more technically challenging than onlay technique
Inlay tecnique
 Mesh cut to size of abdominal wall defect,
placed within fascial defect and sutured to
fascial edges
 Abandoned because of high failure rates
Intraperitoneal onlay position
(IPOM)
 Mesh placed intraabdominally on the
peritoneum
 2 techniques – keyhole or Sugarbaker
Keyhole technique
Sugarbaker technique
[HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a
systematic review of literature. Ann Surg 255(4): 685-695]
Sugarbaker technique
 Sugarbaker first described his technique in 1980
 Technique:
 trephine opening is covered with an intraperitoneally placed mesh via a
laparotomy and sutured to fascial edge
 bowel is lateralized passing from hernia sac between the abdominal
wall and mesh into the peritoneal cavity
 later modified to provide at least 5cm overlap of mesh and adjacent
fascia
 Advantage
 generous mesh overlap
 flap valve effect created able to withstand increased intraabdominal
pressure
 Disadvantage
 mesh related complications
 dense adhesions causing intestinal obstruction requiring laparotomy
 bowel erosion & fistula formation
 Main application of these techniques is in laparoscopic repair
IPOM
[HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a
systematic review of literature. Ann Surg 255(4): 685-695]
Laparscopic techniques
 Key-hole vs modified sugarbaker vs sandwich technique
 Potential advantages
 minimal additional injury to abdominal wall which is already at risk of
herniation
 better view of defect allowing more precise repair and reinforcement
with a mesh
 concomitant incisional hernia repair
 faster postop recovery and decreased postop pain
 Sandwich technique
[Berger D, Bientzle M. Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair. A prospective, observational study with 344
patients. Hernia. 2009;13:167-172.]
Laparoscopic techniques
 Key-hole vs modified sugarbaker vs sandwich technique
 Recurrence rate:
 Keyhole 34.6%
 Sugarbaker 11.6%
 Sandwich 2.1%
 Conversion rate 3.6%
 reasons: multiple dense adhesions, bowel injury, inaccessible abdomen
 Mesh infection rate 2.7%
 Wound infection 3.3%
 Other complication rates 12.7%
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bowel injury 4.1% (15/363)
5 repaired laparoscopically (1 hernia repair was postponed)
6 converted to open
4 were undetected (small bowel injury) during operation (3 required
reoperation, 1 resulted in multiorgan failure and death)
Lap vs Open techniques
 Mesh techniques did not differ significantly in
terms of recurrence
 Overall laparoscopic repair had no advantage
over open repair
[HanssonBM, Slater NJ, Schouten van der Velden AP, Groenewoud HM, Buyne OR, de Hingh IH, Beichrodt RP (2012) Surgical techniques for parastomal hernia repair: a
systematic review of literature. Ann Surg 255(4): 685-695]
Prevention
 High incidence of parastomal hernia
together with unsatisfactory results of its
repair and morbidity associated with
operation lead to emphasis on prevention
 Prevention strategies
 surgical techniques
 prophylactic mesh insertion
Surgical techniques in prevention
 Through or lateral rectus abdominis
 only retrospective studies found lower rate of PSH
with stomas formed through the rectus muscle
 nonetheless probably wise to bring out stoma
throught rectus abdominis ms as this is not
associated with any disadvantage
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Fascial fixation
Closure of lateral space
Trephine size
Extraperitoneal route for stoma construction
Extraperitoneal route for permanent
colostomy
 Few studies had shown that extraperitoneal approach can achieve lower
risk of herniation than transperitoneal route
 Potential disadvantage
 longer operative time
 may need mobilization of splenic flexure for extra length
 Goligher first published the formation of extraperitoneal colostomy in 1958
 extraperitoneal route provides an oblique passage of bowel and eliminate the
lateral peritoneal space without using suture
 attempt to reduce risk of postop small bowel obstruction due to internal
herniation into lateral peritoneal space and reduce parastomal hernia
 Since then, subsequent studies have been published with inconsistent
results
 Only 2 retrospective studies found extraperitoneal colostomy construction
was associated with a lower rate of parastomal herniation than
intraperitoneal route
 most studies were observational retrospective studies with small numbers of
patients undergoing extraperitoneal colostomy and follow up period was not
mentioned
 Studies of highter quality, including RCTS with larger no. of patients are
needed
Prophylactic mesh insertion
 Bayer and colleagues first described mesh insertion at
the time of primary stoma formation in 1986
 Since then many observational studies confirmed the
safety and effectiveness of prophylactic mesh insertion
with low morbidity
 Three RCTs (2008-2009) have shown that prophylactic
mesh in sublay position is associated with reduction in
parastomal hernia when compared with standard stoma
formation
 Systematic review including the three RCTs found a
statistically significant difference in the incidence of PSH
in the mesh gp 12.5% and in the no-mesh gp 53%, but
no difference in morbidity
[Shabbir J, Chaudhary BN, Dawson R. A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation. Colorectal
Dis 2012;14(8):931-6.]
RCTs
Study
Serra
Aracil
Janes
Hammond
Operative
technique
Patient types
No. of patients
Type of mesh
elective
Mesh 27,
no mesh 27
Ultrapro (polypropylene + polygelcaprone 25)
Sublay
Mesh 27,
no mesh 27
Vypro (polypropylene + polyglactin 910)
Sublay
Mesh 10,
no mesh 10
Permacol (porcine derived crosslinked collagen
implant)
Sublay
elective &
emergency
elective
RCTs (cont)
Loss to follow
up
Study
Serra
Aracil
Janes
Hammond
Randomizati
on
sealed
envelope
Blinding
Evaluation of hernia
assessor
Physical examination +
CT abdomen
Follow up /
months
Mesh
No mesh
Median 29
(range 1349)
0
0
6/27 at 12mo,
6/21 between
1-5yrs
1/27 before
12mo,
5/26 between
1-5yrs
0
0
not mentioned
assessor
Physical examination
only
Mean 65.2
(range 5783)
sealed
envelope
double
Physical examination +
stoma site USG
Median 6.5
(range 1-12)
RCTs (cont)
Parastomal
hernia
Study
Serra
Aracil
Mesh
Infection
No mesh
6/27 (22.2%) 12/27 (44.4%)
Mesh
complication
s
Mesh
No mesh
1/27 (3.7%)
1/27 (3.7%)
0
Janes
2/15 (13%)
17/21 (81%)
0
0
0
Hammond
0/10 (0%)
3/10 (30%)
0
0
0
Conclusion
 Concerning repair
 Mesh repair result in lower recurrence rate
 Mesh techniques did not differ significantly in terms of
recurrence or morbidity
 Low overall rate of mesh infection and comparable for
each mesh repair
 Overall laparoscopic repair had no advantage over
open repair
 Concerning prevention
 Meticulous surgical technique
 Adequately powered RCTs is still needed before
recommendation of prophylactic mesh insertion
Discussion