Stoma Hernia

What is Stoma Hernia?

• A stomal hernia is a type of incisional hernia where stoma protrudes from its site in the abdomen.
• A parastomal hernia is a protrusion of abdominal contents (commonly bowel or fatty omentum) through a weakness in the abdominal wall at the site of the previous hole made for delivering the stoma.

Causes

• Stomal hernias result when there is a widening of the surgical hole created in the abdominal wall at the time of original stoma formation.
• This hernia results from tangential forces that stretch on the trephine over time. They are a common and difficult complication to manage. In fact some degree of herniation is argued to be inevitable, and does not always represent a true hernia.

Types

Sucutaneous – the hernia occurs alongside the bowel for the stoma and bulges into the fatty spaced just under the skin (subcutaneous space).
Interstitial – the hernia occurs alongside the bowel for the stoma, then bulges into the abdominal wall sliding between the muscles of the abdominal.
Perstomal – relates only to the prolapsing loop stoma, and is where loops of bowel and or omentum enter the hernia space produced between the two loops of prolapsed bowel.
Intrastomal – the hernia occurs alongside the bowel for the stoma and enters the plane between the emerging and the everted part of the bowel. It typically occurs in prolapsing end stomas or stomas with excessive spouting.

Symptoms

• Pain
• Abdominal bloating
• Vomiting

Risk Factors

• Obesity
• Emergency procedure
• Weight gain after stoma formation
• Poor nutrition
• Immunosuppression (including use of steroids and biologics)
• Emphysema and smokers (chronic cough leads to raised intra-abdominal pressures)
• Inflammatory bowel disease (Crohn’s and ulcerative colitis)

Treatment

• Most para-stomal hernias are asymptomatic and require reassurance that a surgical repair is not needed.
- A cautious approach should also be taken for those with mild symptoms, particularly if frail or significant other illnesses exist, because of the high recurrence rates following surgery.
- Most patients with mild symptoms can be managed with stoma hernia belt which is much like a corset.
- Life threatening complications are rare. Urgent or emergency repair is sometimes needed because of obstruction or risk of bowel twisting or strangulating. Patients should be educated about signs and symptoms of acute obstruction or strangulation which include vomiting, abdominal pain, and extreme tenderness over the hernia. If these occur, the patient should be advised to present to hospital early to be assessed by a surgeon.

• Surgery (with / without mesh)
Common indications for elective repair include:
a) Increasing size of the para-stomal hernia
b) Skin breakdown or dermatitis around the stoma
c) Intermittent bowel obstruction
d) Stoma appliance dysfunction and leakage
Note: Laparoscopic para-stomal hernia repair has more recently increased in popularity.