1. Parastomal hernias occur when viscus penetrates the abdominal wall around ostomies like colostomies and ileostomies. Inadequate wound healing between the ostomy tunnel and abdominal wall causes hernias. 2. Parastomal hernias are classified by location as subcutaneous, interstitial, perstomal, or intrastomal. 3. Surgical repair techniques include relocating the stoma, direct repair with or without mesh, indirect repair using mesh, and laparoscopic repair. Placement of a prophylactic mesh may reduce hernia rates.

1. Prevention & Management of Parastomal Hernia
Dr. K. Sendhil Kumar
MS, FICS, FACS(USA), DNB (SGE)
Dr. Piyush Patwa
DNB, FMAS, FIAGES, FIAS
Gateway Clinics, Coimbatore, India

3. PARASTOMAL HERNIA
Introduction
• PARASTOMAL HERNIA : An ostomy is an artificial opening through the abdominal wall for the intestine
or ureter in order to discharge feces or urine. Hernias that are associated with colostomies, ileostomies,
jejunostomies or urostomies, where viscus penetrates the abdominal wall are called as paraostomal hernias.
• Causes :
1. inadequate wound healing between the ostomy tunnel & the viscus that extends through the abdominal
wall.
2. Any condition that decreases wound healing in the early postoperative period will increase the incidence of
paraostomal hernia.
3. Poor nutrition, progressive cancer, obesity
4. Poor surgical technique that interfere with adherence of bowel wall and abdominal wall
5. The others are coughing, sneezing & ascites.

4. Classification
• Subcutaneous: Herniation in subcutaneous fat
• Interstitial: Herniation into the intermuscular planes
• Perstomal: Loops of bowel and/or omentum enter the hernia space
produced between the layers of the prolapsed bowel
• Intrastomal: Herniation extrudes from the abdomen alongside the bowel for
the stoma

6. PSH Repair - Technique
• Common aspect of all of the approaches
• Reduction of the hernia contents into the abdominal cavity
• Closure of the defect by securing a piece of mesh under the defect with wide overlap
• The bowel forming the ostomy is either brought out directly through a defect in the
mesh, the "key hole" technique, or around the mesh

7. PSH Repair - Technique
• Surgical Repair:
• Relocation of the stoma
• Direct repair of the fascialdefect with or without prosthetic mesh
• Repair using a prosthetic mesh
• Laparoscopic repair

8. Parastomal HerniaTechnique-Keyhole (direct)
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9. Parastomal Hernia
Sugar-Baker Technique (Indirect)
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26. Video

27. Parastomal Hernia Prevention
 Attention to proper surgical technique:
• Well vascularized
• Non-traumatized
• Tension free anastomosis between the skin and intestine
 A stoma should never be brought out through the laparotomy wound
 The stoma should be brought through the rectus abdominis muscle
 Higher rates of hernia formation occur when the stoma is brought lateral to the
rectus

28. Conclusion
 The opening should be made large enough to allow the bowel to pass
 Diameter of the opening should be around 2.5 cm, or two to three of the surgeon’s
fingers
 Larger openings in the abdominal wall, may be associated with an increased risk of
parastomal herniation
 The only method that has reduced the rate of parastomal hernia in a randomized
trial is the use of a prophylactic mesh
 Randomized trials, prospective observational studies, and descriptive techniques
promote a benefit for prophylactic mesh placement

29. Conclusion
• Suture repair of Parastomal hernia should be abandoned because of increased
recurrence rates.
• The use of mesh in Parastomal hernia repair significantly reduces recurrence rates
and is safe with a low overall rate of mesh infection.

30. Conclusion
• Despite a long list of suggesting predisposing factors for Parastomal hernia
formation (including obesity, corticosteroid use and obstructive pulmonary disease),
few have been studied and found to be truly instrumental in increasing the risk.