parastomal hernia repair guidelines 2020 classification

1. Guidelines on
prevention and
treatment of
parastomal hernia
Georges KHALIFEH , FFI
GHPSO
Chirurgie digestive et viscérale

2. “Some degree of herniation around a colostomy is so common
that this complication may be regarded as inevitable”
Goligher

4.  What is the incidence of parastomal hernias?
 Is there a difference in the incidence of parastomal hernia for
colostomy, ileostomy or ileal conduit?

5. INCIDENCE
Estimation de l’incidence globale de la hernie parastomiale:
 30 % à 12 mois
 40 % à 2 ans
 50 % lors d’un suivi supérieur
La colostomie terminale est associée à une incidence plus élevée
de hernie parastomiale , en comparaison à la colostomie latérale
ou à l’iléostomie latérale.

6. Parastomal Hernia Risks Factors
Patient factors
 Age
 Intra-abdominal pressure factors
 Obesity
 Emphysema
Wound healing factors
 Infection
 Steroids
 Genetics (collagen deficiency)
Surgical Technique
 Site outside of rectus sheath
 Stoma defect created too large

7. Symptoms of parastomal hernia
 Protrusion of stoma beyond abdominal wall
 Prolapse of stoma
 Enlargement of stoma
 Appliance leakage / poor fit
 Pain
 Incarceration or strangulation

8. Classification

9. DEVLIN :
 Subcutaneous
 Interstitial
 Perstomal
 intrastomal

10. Classification radiologique

12. EHS Classification

14. What is the diagnostic accuracy of the
clinical diagnosis of parastomal hernias
versus a diagnosis by medical imaging?
 Physical examination – on lying down and standing with
valsalva
 Digital examination enables the fascial aperture and par
astomal tissues to be assessed
 Imaging

16. Are there techniques for stoma creation
that result in fewer parastomal hernias?
1. Extraperitoneal versus transperitoneal stoma construction
2. Stoma construction at a lateral pararectus location versus a
transrectus location
3. Size of the fascial aperture
No recommendation can be made in preference of stoma construction through
the extraperitoneal over the transperitoneal route.
No recommendation can be made in preference of stoma construction at a
lateral pararectus location over a
transrectus location.
We suggest keeping the size of the fascial
aperture as small as possible to allow passage of the intestine
through the abdominal wall without causing ischemia.

17. Does the use of a prophylactic mesh during
stoma construction reduce the incidence of
parastomal hernias?

20.  Anterior fascial fixation? YES OR NO

21. Indications for hernia repair
Surgical repair is indicated for patients who develop acute
parastomal hernia complications and for those with chronic
symptoms that impair the quality of life.

22. Acute complications
— There is a low rate of life-threatening complications
associated with parastomal hernia .
Urgent or emergent surgical repair is necessary for patients with
a bowel obstruction resulting from an incarcerated hernia
because of the risk for strangulation and bowel ischemia

23. Chronic bothersome symptoms
Patients with chronic symptoms that impair the quality of life are listed
below, and patients may benefit from elective hernia repair.
●Stoma appliance dysfunction and leakage not responsive to
conservative measures.
●Peristomal skin breakdown related to shear injury or ischemia from
pressure on the thinned peristomal skin.
●Recurrent partial bowel obstruction.
●Chronic abdominal pain related to the parastomal hernia.

24. Management
1. Conservative
2. Surgery
 Closure of stoma
 Direct fascial repair
 Relocation
 Mesh repair

25. Is there a place for watchful waiting in
patients with a parastomal hernia?

27. Direct fascial repair
Reduce size of hernia defect by reapproximating the fascial edges of trephine with sutures
Advantage :
 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 46 100%

28. Is a suture repair for elective parastomal
hernia repair an option?
It is recommended not to perform a suture repair for elective
parastomal hernia surgery because of a high risk of recurrence,
This approach should be reserved for patients with co-morbidities, short life expectancy
or with a contra-indication for suture repair with prosthetic reinforcement (emergency
surgery, strangulation with ischemic compromise, cirrhotic patients with ascites. . .).

29. Stoma relocation
 Advantage:
 useful if the current stoma position unsatisfactory
 can be done with or without laparotomy
 lower recurrence rate than direct fascial repair
 Disadvantage:
 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

30. Relocation + mesh

31. Prosthesis after stoma relocation.
Some authors propose placement of prosthesis
covering the two sites, the stoma and the midline
incision, to prevent recurrent abdominal
wall hernia

32. Stoma relocation
This approach avoided because the new stoma at new site is associated with
the same high risk of hernia formation

33. Mesh repair
 Overall recurrence rates after mesh repair vary between 7-
17% (depending on technique and placement of mesh)
 Overall mesh infection rate 2.4%
 Risk of mesh infection did not differ between mesh
techniques

34. 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

35. Onlay technique
Advantage:
 more straight forward surgical technique involving a mesh
 avoids intra-abdominal dissection
Disadvantage:
 higher risk of contamination & sepsis than sublay technique
 extensive dissection of subcutaneous tissue
 predisposes to hematoma / seroma formation
 risk for ischemic injury to skin => impair wound healing
 Intra-abdominal pressure may lead to detachment of mesh resulting
in recurrence

36. Onlay

37. Sublay technique
 Mesh placed between rectus muscle and posterior sheath
 Fewer studies evaluating this method of mesh placement
 Small series with relatively short follow up (most <12mo)
 Overall recurrence rate 6.9%

38. Sublay technique
Advantage
 intraabdominal pressure does not dislocate the mesh from
repairno direct contact with bowel
Disadvantage
 more technically challenging than onlay technique

39. 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

40. Intraperitoneal onlay position (IPOM)
Mesh placed intraabdominally on the peritoneum
2 techniques
 Sugarbaker technique
 Keyhole technique

42. Sugarbaker
technique
 Sugarbaker first described his technique
in 1980
 intraperitoneally placed mesh via a
laparotomy and sutured to fascial edge
 bowel is lateralized
 overlap of mesh and adjacent fascia
Advantage:
 generous mesh overlap
 flap valve effect created able to withstand
increased intraabdominal pressure

43. Sugarbaker
technique
Disadvantage:
 mesh related complications
 dense adhesions causing intestinal obstruction
requiring laparotomy
 bowel erosion & fistula formation
Main application of these techniques is in laparoscopic
repair

45. Technique de cuilleret

46. Modified sandwich

48. The following recurrence rates were noted:
Primary suture repair – 69.4 percent
 Onlay mesh – 17.2 percent
 Sublay mesh – 6.9 percent
Open, intraperitoneal mesh
 Sugarbaker – 15 percent
 Keyhole – 7.2 percent
Laparoscopic mesh
 •Sugarbaker - 11.6 percent
 •Keyhole – 11.6 percent
 •Sandwich – 2.1 percent

49. Laparoscopic techniques
 Conversion rate 3.6%
 Mesh infection rate 2.7%
 Wound infection 3.3%
 bowel injury 4.1%

50.  For patients with appropriate indications for repair who have
small defects (<5 inches), and no expectation of significant
intra-abdominal adhesions, we suggest a laparoscopic
approach rather than open repair

52. Laparoscopic laparotomy
 When feasible, laparoscopic ostomy formation is preferred to
ostomy formation via laparotomy.
 Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

53. Loop ileostomy transverse loop
 Loop ileostomy is preferred over transverse loop colostomy for
temporary fecal diversion in most cases.
 Grade of Recommendation: Weak recommendation based on moderate-quality evidence, 2B.

54. Prophylactic mesh?
 Lightweight polypropylene mesh may be placed at the time of
permanent ostomy creation to decrease parastomal hernia
rates.
 Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B

55. Extraperitoneal tunneling of end
colostomies?
 Extraperitoneal tunneling of end colostomies may decrease
parastomal hernia rates.
 Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C.

56. stomy-site skin closure?
 Stomy-site skin reapproximation should be performed when
feasible, and pursestring skin closure may have advantages
compared with other techniques.
 Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.

57. Parastomal hernia repair !
 Parastomal hernia repair should typically be performed by
using mesh reinforcement or by relocating the stoma.
 Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

58. Prosthetic mesh increase infection, erosion ?
 Prosthetic mesh may be used during parastomal hernia repair
with low short-term risk of intestinal erosion or mesh infection.
 Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

59. Collagen based bioprosthetic grafts?
 Bioprosthetic material may be used as an alternative to
synthetic mesh for repair of parastomal hernias.
 Grade of Recommendation: Weak recommendation based on low quality evidence, 2C.

60. Laparoscopic parastomal hernia repair
 Laparoscopic parastomal hernia repair with mesh may be a
safe alternative to open mesh repair.
 Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

61. There are some intra and post-operative
measures that can help to prevent the
development of parastomal hernias, such as:
 Correct positioning, placing the orifice through the rectus
muscle
 Avoiding excessive opening of the fascia (as small as possible,
as long as it doesn’t compromise stoma perfusion)
 Wearing a support garment (belt or underwear)
 Avoiding heavy lifting and straining
 Avoiding being overweight and maintaining a normal body
mass index when possible

63.  Thank you