Parastomal Hernia - UpToDate

12.02.
2022, 09:46 Parastomal hernia - UpToDate
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Parastomal hernia
Author: Robert R Cima, MD, MA, FACS, FASCRS
Section Editor: Michael Rosen, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2022. | This topic last updated: Oct 27, 2021.
INTRODUCTION
Parastomal hernia is the most frequent complication following the construction of a colostomy
or an ileostomy, occurring in up to 50 percent of patients. A parastomal hernia is a type of
incisional hernia that allows protrusion of abdominal contents through the abdominal wall
defect created during ostomy formation ( image 1). It should be recognized that, unlike a
hernia development in a surgical incision for which the fundamental problem is healing
between tissues that have been approximated, ostomy creation introduces an abdominal wall
defect, the trephine, for which no healing is expected. A parastomal hernia forms as the
trephine is continually stretched by the forces tangential to its circumference [1].
The construction of an ostomy and the management of patients with an ileostomy or colostomy
are reviewed separately. (See "Overview of surgical ostomy for fecal diversion" and "Ileostomy
or colostomy care and complications".)
EPIDEMIOLOGY AND RISK FACTORS
The reported incidence of parastomal hernia varies widely and is related to the type of ostomy
constructed, the duration of follow-up after ostomy construction, and the definition used to
identify parastomal hernia. The incidence of parastomal hernia is reported as ranging from 0 to
50 percent, depending upon the type of ostomy [2-12]. One review found the following rates of
parastomal hernia formation [12]:
● End ileostomy – 1.8 to 28.3 percent
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12.02.2022, 09:46 Parastomal hernia - UpToDate
● End colostomy – 4.0 to 48.1 percent

● Loop ileostomy – 0 to 6.2 percent
● Loop colostomy – 0 to 30.8 percent
The lower rate for loop ostomy is related to the frequently temporary nature of most of these
stomas and the short duration of follow-up. By contrast, the Swedish National Colorectal Cancer
Registry and National Patient Register were used to identify colorectal cancer patients with a
permanent colostomy. In over 6000 patients followed between 2007 and 2013, the cumulative
incidence of patients either diagnosed with or surgically treated for a parastomal hernia was 7.7
percent [13]. The only identified risk factor for parastomal hernia development in this cohort
was a body mass index (BMI) >30 kg/m2.
The incidence of parastomal hernia is also influenced by the means of construction. The
incidence is lower for isolated laparoscopic ostomy construction (0 to 6.7 percent) compared
with trephine single-incision ostomy construction (6.7 to 12 percent), and even higher when
ostomy construction is combined with other procedures or open abdominal exploration. The
placement of prophylactic mesh at the time of ostomy construction is associated with a
significant decline in parastomal hernia formation (0 to 8.3 percent) [14-18]. (See "Overview of
surgical ostomy for fecal diversion".)
Risk factors — Factors that increase the risk of parastomal hernia can be regarded as
predominantly patient specific or technique specific.
Patient-specific factors include advanced age, wound infection, chronic or recurrent increases in
intra-abdominal pressure, chronic obstructive pulmonary disease, obesity, abdominal wall
strength, weight gain after ostomy construction, malnutrition, glucocorticoids,
immunosuppression, malignancy, and inflammatory bowel disease [6,12,19-21]. Among these,
obesity, defined as waist circumference >100 cm or BMI >30 kg/m2, is best supported by clinical
evidence [6,21].
Technical factors that might influence the risk of parastomal hernia formation include
emergency stoma placement and surgical technique for ostomy construction (open,
laparoscopic). The diameter of the trephine in the abdominal wall fascia may be particularly
important. An analysis of the forces acting upon the trephine that cause dilatation, and thus a
hernia, revealed that the larger the trephine radius, the greater the tangential force pulling the
trephine apart [1]. This physical analysis supports the clinical findings that parastomal hernia is
less common following an ileostomy compared with colostomy and end stoma compared with
loop stoma [22]. One study evaluated patients with permanent colostomies and found that at a
mean follow-up of 26 months, no patient with an abdominal wall diameter ≤25 mm developed a

parastomal hernia, which supports the concept that a smaller trephine is less likely to lead to
parastomal hernia [23].
CLINICAL FEATURES
Most parastomal hernias occur within the first two years of construction, and studies with
longer follow-up report higher parastomal hernia rates [7,20,24]. As with other types of
abdominal wall hernias, patients typically present with a bulge at the stoma site ( picture 1) or
adjacent to it, with or without pain. A minor degree of parastomal abdominal wall weakness
may be present in many patients, but this does not represent a true hernia [22]. (See "Overview
of abdominal wall hernias in adults".)
Pain that does manifest can be mild abdominal discomfort, back pain, intermittent cramping, or
more severe pain. In a French study of 782 patients, 25 percent developed parastomal hernia,
of whom 76 percent had symptoms; however, only one-half of these patients had symptoms
that were sufficiently bothersome to warrant repair [20]. The main complaints were pain
occurring in 35 percent and difficulties in fitting a stomal appliance with leakage in 28 percent.
Pain might also be due to peristomal skin irritation/breakdown related to stoma appliance
leakage because of poor appliance fit related to the hernia. Peristomal pressure ulcers may
develop as patients try to compensate for poor appliance fit by increasing appliance convexity
or use belts to hold the appliance in place.
Patients with incarcerated or strangulated bowel within the hernia sac can have symptoms of
bowel obstruction with nausea, vomiting, severe abdominal pain, and obstipation. Patients will
frequently report significant "hardness" and pain at the site of the hernia if that is the site of the
obstruction. (See 'Acute complications' below and "Etiologies, clinical manifestations, and
diagnosis of mechanical small bowel obstruction in adults", section on 'Clinical presentations'.)
After removal of the appliance, the patient should be examined in the standing position and
asked to perform the Valsalva maneuver. The peristomal skin needs to be evaluated for
evidence of injury reflecting leakage or excessive appliance contact pressure. The extent of the
hernia defect can be assessed by examining the paracolostomy or para-ileostomy tissue [12]. It
is important to determine if the hernia sac content can be reduced. A digital examination of the
stoma might provide further information if there are concerns about the abdominal wall or the
hernia defect contributing to stoma dysfunction.
CLASSIFICATION

Several classifications for parastomal hernia have been proposed, but none are universally
accepted [25-28]. Although these classification schemes may be useful in research and for
academic discussions, in clinical practice there is little added value since management is based
upon the symptoms induced by the hernia. These different types of hernia basically are treated
in the same manner.
One of these classifications separates parastomal hernia into four subgroups based on the
location of the hernia sac, which can contain bowel or omentum, but practically speaking,
differences in hernia location and composition may be difficult to appreciate on physical
examination ( figure 1) [26]:
● Interstitial – The herniation extrudes alongside the bowel for the stoma, then burrows into
one of the intermuscular planes.
● Subcutaneous (most common type) – The herniation extrudes from the abdomen
alongside the bowel for the stoma and bulges into the subcutaneous fat alongside the
stoma.
● Intrastomal – The herniation extrudes from the abdomen alongside the bowel for the
stoma and enters the plane between the emerging and the everted part of the bowel. It
usually occurs in the spout type of stoma, such as an ileostomy.
● Peristomal – The stomal bowel is prolapsed, and loops of bowel and/or omentum enter
the hernia space produced between the layers of the prolapsed bowel.
A radiologic classification scheme using findings from cross-sectional imaging has also been
developed [29]. This scheme distinguishes between possible contents of the hernia sac,
including omentum, the loop of bowel forming the ostomy, and other loops of bowel not
forming the ostomy.
DIAGNOSIS
A diagnosis of parastomal hernia is primarily clinical and can usually be made by history and
physical examination of stoma. Patients with classic symptoms of a parastomal hernia and a
negative examination of the abdominal wall and stoma generally do not require any imaging.
However, patients with obstructive symptoms should undergo further imaging studies,
preferably a computed tomography (CT) of the abdomen to exclude other pathologies that
could mimic or complicate a parastomal hernia. Ultrasound can only define the extent and
degree of small para-ostomy hernias.
Differential diagnosis — For patients with abdominal complaints and a stoma, few entities
would be confused for parastomal hernia. However, if the stoma is close to a midline incision,
clinical findings may be due to an incisional hernia rather than related to the stoma. For
patients with obstructive symptoms (nausea, vomiting, abdominal distention, obstipation) for
whom examination of the stoma cannot account for the degree of symptoms, abdominal CT is
warranted to identify the severity and location of the obstruction, which may not be related to
the stoma ( image 1), though a negative CT scan does not exclude a parastomal hernia (as it
might only be present when the patient is upright). (See "Etiologies, clinical manifestations, and
diagnosis of mechanical small bowel obstruction in adults", section on 'Diagnosis'.)
MANAGEMENT
Most patients with a parastomal hernia do not have symptoms that are sufficiently bothersome
to warrant repair. For patients with no or only mild symptoms, we suggest conservative
management with measures to improve patient comfort and ostomy functioning. Surgical
repair is generally avoided due to the propensity for parastomal hernia to recur. (See
'Recurrence' below and 'Recurrent parastomal hernia repair' below.)
Patients who are being conservatively managed should be educated about signs and symptoms
of bowel obstruction and bowel strangulation/infarction and should be instructed to seek
medical attention if such symptoms occur to avoid delays in diagnosis, which can be life-
threatening. Patients can call their surgeon or primary care provider or go to the nearest
emergency room. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small
bowel obstruction in adults", section on 'Acute small bowel obstruction'.)
Stoma care — Patients without indications for surgery can be managed with a stoma belt
(ostomy binder) [12]. A stoma belt is designed to provide stability around the stoma site to
minimize bulging at the skin level. The main goal is not to reduce the hernia but to help fix the
appliance in a stable position and lessen shearing, which causes the ostomy appliance to leak.
When a stoma belt is appropriately sized by a wound/ostomy nurse, there are few, if any,
complications. Issues related to ostomy care, including methods of limiting ostomy leakage and
peristomal skin breakdown, ostomy trauma, and abdominal distention from excessive gas, are
discussed in detail elsewhere. (See "Ileostomy or colostomy care and complications".)
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. (See 'Clinical features' above.)

Acute complications — There is a low rate of life-threatening complications associated with

parastomal hernia [12,22]. Urgent surgical repair is necessary for patients with a bowel
obstruction resulting from an incarcerated hernia because of the risk for strangulation and
bowel ischemia. (See "Management of small bowel obstruction in adults", section on
'Indications for immediate surgery'.)
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.
● Chronic back pain or hip pain related to the parastomal hernia [30].
● Psychological distress caused by any of the previous symptoms. The evaluation of

psychological effects of parastomal hernia should be individualized. For some patients,
the fear of stomal leakage in public is debilitating.
MESH FOR PARASTOMAL HERNIA REPAIR
Various types of mesh (polypropylene, expanded polytetrafluoroethylene [ePTFE], biologic) have

been used in the repair of parastomal hernia. A systematic review of parastomal hernia repair
techniques found no significant differences for one type of repair over the other with respect to
mesh-related complications [31]. The risk of recurrent parastomal hernia was reduced when
mesh was used compared with primary stoma repair [15-18,32-44]; however, parastomal hernia
can still occur, but there are limited data regarding parastomal hernia that has occurred in spite
of prophylactic mesh placement. (See 'Primary repair versus mesh repair' below.)
The use of a biologic substitute obviates the placement of prosthetic mesh material near the
stoma [33], which is a contaminated site. Although data are limited regarding the use of
biologic substitutes for repair of parastomal hernia [45-47], these should be considered in
patients who are at high risk for prosthetic mesh complications, such as those with
inflammatory bowel disease [48] or risk factors for wound infection. The expense of biologic
substitutes, which can cost thousands of dollars per piece, probably cannot be justified for
others. A systematic review identified four retrospective studies with a total of 57 patients, with
all reports using a collagen-based biologic scaffold to reinforce or bridge the parastomal hernia
defect [45]. Although wound complications occurred in 26 percent, there were no wound
infections. Recurrence occurred in 16 percent of patients, a rate comparable to the failure rate
of parastomal hernia repair using prosthetic mesh. (See 'Recurrence' below.)
SURGICAL APPROACH
There are many options for parastomal hernia repair using differing approaches ( figure 2)
[11,31,49-75]. Each has advantages and disadvantages. Parastomal hernias are repaired using
various standard surgical techniques, but there is no one repair technique that is suited to all
clinical situations, and all techniques are associated with hernia recurrence.
The general approaches for managing parastomal hernia include primary repair, mesh repair,
and relocation of the stoma.
● Primary repair of the parastomal hernia is technically simple, avoids manipulation of the
abdominal contents, and has low morbidity, but excessive tension on the repair leads to
high recurrence rates. (See 'Primary repair' below and 'Recurrence' below.)
● Prosthetic mesh repair, which is the most common type of repair, closes the hernia defect
using mesh placed anterior to the rectus or external oblique fascia (onlay) or below the
fascia and muscular layers (preperitoneal or sublay technique) ( figure 3). The mesh
onlay technique is performed using open techniques, while the sublay technique is
performed from an intra-abdominal approach (open or laparoscopic/robotic). (See 'Onlay
versus sublay mesh' below and 'Onlay mesh repair' below and 'Intra-abdominal repair
with mesh' below.)
● Relocation of the stoma to another site on the abdominal wall was once a common
approach but is generally avoided because the new stoma is associated with the same
high risk of hernia formation as the initial stoma [70,76]. The recurrence rate is
approximately 36 percent (range 0 to 76 percent), and complication rates are as high as 88
percent [70,71,76]. When this option is chosen, the abandoned stoma site should be
repaired using a mesh technique (onlay or sublay) rather than with a primary repair to
avoid recurrent hernia and, more importantly, to limit tension on the abdominal wall that
could lead to hernia formation at the new stoma site. (See "Overview of surgical ostomy
for fecal diversion".)

Primary repair versus mesh repair — The overall success rate for parastomal hernia repair
with mesh is relatively high compared with repair not using mesh. In a systematic review
analyzing various techniques for repair of parastomal hernia, the risk for recurrent parastomal
hernia was significantly higher for primary suture repair compared with mesh repair (odds ratio
[OR] 8.9, 95% CI 5.2-15) [31]. However, all reports were nonrandomized, included small numbers
of patients, and had variable follow-up. Mesh repair is still associated with recurrence rates of
up to 30 percent [31,56,57,70-75].
Complications such as contamination of the mesh, erosion, and fistula formation, while rare,
can be difficult to manage [74]. Thus, in general, although mesh repair is desirable, there may
be circumstances under which a primary repair or relocation of the stoma may be preferred,
even though the risk of recurrence is higher.
Open versus laparoscopic repair — Reports of decreased patient morbidity and improved

outcomes with laparoscopic tension-free mesh repair of ventral and incisional hernias have led
surgeons to apply these techniques to the repair of parastomal hernia [31,49,77-83].
There are very few data to determine which patients with parastomal hernia are best treated via
a laparoscopic approach or an open approach. Based upon the experience with midline
incisional hernias, laparoscopic repair is also best reserved for when the surgeon does not
anticipate extensive intestinal adhesions or extensive anterior peritoneal wall scarring from
prior surgery [84]. A laparoscopic approach may also be preferred for patients with smaller (<8
to 12 cm) hernias.
Onlay versus sublay mesh — The onlay mesh technique has the advantage of being
technically straightforward and avoids the intra-abdominal dissection required for a sublay
approach, which increases the risk for future abdominal adhesions and intestinal obstruction.
However, similar to the surgical experience with incisional hernia repairs, the sublay technique
is associated with fewer recurrences because intra-abdominal pressure cannot dislocate the
mesh from the repair [85]. The main problems with the sublay technique are identifying the
best material for the mesh and establishing the best site for its placement. The onlay technique
is associated with a higher risk of wound/mesh infection.
TECHNIQUES
Primary repair — Parastomal hernia repair was once performed in a manner similar to

traditional primary suture repairs of inguinal and incisional hernias, reducing the size of the
hernia defect by reapproximating the fascial edges of the trephine with permanent sutures.

Primary repair involves a dissection of the fascia at the site of the stoma. This approach can be
performed locally at the parastomal hernia site extra-abdominally, intra-abdominally via a
laparotomy incision, or laparoscopically. This approach is generally avoided because the physics
of parastomal hernia and the nature of the defect unavoidably create tension on the repair,
which leads to a high rate of recurrence.
Onlay mesh repair — Onlay mesh repair is performed by making an incision in the abdominal
wall, typically in the midline, well away from the stoma. In some situations, a lateral incision
may be appropriate. A subcutaneous dissection along the rectus and oblique fascia is
performed circumferentially around the stoma. The contents of the hernia are reduced into the
abdomen, and the abdominal wall defect is closed using a tension-free mesh repair. While all of
the series describing this technique are small, nonrandomized, and lack long-term follow-up,
these reports describe low perioperative complication rates but recurrence rates ranging from 0
to 20 percent.
Undermining the skin around the stoma also risks ischemic injury to the skin, which can result
in significant management problems with the stoma appliance. The use of closed suction drains
overlying the mesh appears to reduce complications resulting from seroma collections [57];
however, this needs to be balanced against the possible risk of mesh infection, which is higher
for this technique than for intraperitoneal placement of mesh.
Intra-abdominal repair with mesh — The common aspect of each of the various approaches
to intraperitoneal mesh placement is reduction of the hernia contents into the abdominal cavity
and closure of the fascial defect by securing a piece of mesh under the defect with wide overlap
onto the normal abdominal wall. Intra-abdominal access is usually accomplished by reopening
the prior midline incision, but the incision can be made at other positions on the abdominal wall
depending upon the size and nature of the parastomal hernia defect. However, the incision
needs to be far enough away from the stoma to ensure that the stoma appliance will not cover
the incision.
The loop of bowel forming the ostomy can be brought around the mesh (eg, Sugarbaker
technique), similar to extraperitoneal ostomy construction, or directly through a defect in the
mesh (ie, the "keyhole" technique) ( figure 4).
● Sugarbaker technique – Sugarbaker was the first to describe the intraperitoneal mesh
repair of a parastomal hernia [59]. This technique involves securing the mesh over the
entire fascial defect circumferentially, but laterally, to create a mesh flap valve around the
stoma. This prevents herniation and contact with the stoma bud, theoretically reducing
infection. The bowel loop exiting at the stoma site is secured to the lateral and anterior

abdominal wall, and then a large piece of mesh is attached to the anterior and lateral
abdominal wall over this loop of bowel, preventing other loops of bowel from contacting
or protruding through the abdominal wall at the trephine for the stoma.
● Keyhole technique – In the keyhole technique, a 2 to 3 cm "keyhole" cut-out is made to

surround the ostomy while covering the entire hernia defect (Von Sprundel, Morris,
Hofstetter, Byers). However, there is a risk of obstructing the enterostomy if a small
keyhole is made and a risk of recurrence if the keyhole is large. Morbidity using this
technique has been overall low.
Laparoscopic approach — The technique of laparoscopic parastomal hernia repair has not

been standardized. Various methods utilizing different mesh materials have been reported by
small, single-surgeon, retrospective studies [55,67,86].
Among them, the laparoscopic modification of the Sugarbaker technique is most widely used
because it does not require apertures to be created in the mesh ( figure 5), which simplifies
its laparoscopic placement [67]. In a retrospective study of 62 patients who underwent
parastomal hernia repairs, the laparoscopic Sugarbaker technique was associated with a lower
complication rate (40 versus 76 percent) and a lower recurrence rate at 20 months (16 versus 60
percent) compared with other laparoscopic techniques [87]. However, longer-term follow-up
results have not been reported for any of the techniques. (See 'Intra-abdominal repair with
mesh' above and 'Recurrence' below.)
RECURRENCE
The various types of parastomal hernia repair are associated with a wide range of recurrence
rates due to variations in the definition of a parastomal hernia recurrence, either radiographic,
clinical, or symptomatic; type of stoma; size of hernia defect; indications for repair; and length
of time of follow-up. Recurrence rates for primary suture repair are high, ranging from 30 to 76
percent [12,20,70,76,88]. In a systematic review, primary suture repair significantly increased
the risk for recurrent hernia compared with mesh repair [31]. There were no significant
differences between open and laparoscopic hernia repair for recurrence; the open Sugarbaker
technique had significantly fewer recurrences compared with a keyhole technique, but this was
not the case for the laparoscopic approach. 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
Recurrent parastomal hernia repair — Recurrent parastomal hernias present many

challenges for repair. Recurrent repair is best done if there was no mesh used previously. If
mesh was used as an onlay or sublay and the hernia recurred, one option is to perform a
Sugarbaker repair. If all else fails, relocating the stoma to the other side of the abdomen and
using prophylactic mesh during creation of the new stoma is the next best option.
PERIOPERATIVE MORBIDITY AND MORTALITY
Perioperative mortality following elective repair of parastomal hernia using commonly

performed mesh repairs is low (<3 percent) but increases in emergency settings [89]. In a
systematic review, laparoscopic repair had no advantage over open repair with respect to
morbidity or mortality [31]. Complications following parastomal hernia repair are similar to
those of any hernia repair and include recurrence (discussed above), inadvertent enterotomy,
postoperative bowel obstruction, surgical site infection, mesh infection, and mesh erosion.
Mesh erosion is a consequence of placing mesh adjacent to the bowel. Shrinkage of the mesh
may lead to late erosion into the bowel [31,74].
Overall, wound/mesh infection rates following parastomal hernia range from 6 to 20 percent
[31,90]. Infection rates for laparoscopic hernia repairs may be lower. Mesh infection results
from contamination of the mesh at the time of placement or late seeding from hematogenous
sources, which is less common but occurs at higher rates following repair of complicated
parastomal hernia (eg, strangulation). (See "Wound infection following repair of abdominal wall
hernia".)
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Parastomal hernia".)
SUMMARY AND RECOMMENDATIONS
● A parastomal hernia is a type of incisional hernia that allows protrusion of abdominal

contents through the abdominal wall defect created during ostomy formation or
immediately adjacent to the stoma. The development of a parastomal hernia is an almost
inevitable complication following the construction of an intestinal stoma. (See
'Introduction' above.)
● Risk factors for parastomal hernia are similar to those for other abdominal hernias and
include advancing age, wound infection, chronic or recurrent increases in intra-abdominal
pressure, chronic obstructive pulmonary disease, obesity, weight gain after ostomy
construction, malnutrition, glucocorticoids, immunosuppression, malignancy, and
inflammatory bowel disease. (See 'Epidemiology and risk factors' above.)
● Most patients with a parastomal hernia are asymptomatic. Patients typically present with a
bulge at the site of or adjacent to the intestinal stoma, with or without associated pain (
picture 1). Symptoms range from mild abdominal discomfort to symptoms of
strangulated bowel obstruction, which can be life-threatening. The diagnosis of
parastomal hernia is based on characteristic findings and physical examination. (See
'Clinical features' above and 'Diagnosis' above.)
● Patients with symptoms and signs of complicated bowel obstruction (complete,

strangulated) should undergo urgent parastomal hernia repair. (See 'Acute complications'
above and "Management of small bowel obstruction in adults".)
● For patients with mild or no symptoms referable to the parastomal hernia, we suggest
conservative management rather than hernia repair (Grade 2C). Standard measures to
care for the ostomy may be sufficient to relieve the patient's symptoms and concerns. If
symptoms persist or the hernia progressively increases in size, the patient may elect
hernia repair. (See 'Management' above and 'Indications for hernia repair' above.)
● For most patients, we suggest using prosthetic mesh for repair of the parastomal hernia
rather than primary, suture repair (Grade 2B). The mesh can be placed extraperitoneally
or intraperitoneally. (See 'Surgical approach' above.)

● 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 (Grade 2C). (See 'Surgical approach' above.)
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Topic 3691 Version 26.0

GRAPHICS
Parastomal hernia on CT
An axial CT scan through the lower abdomen (A) shows a loop of small bowel herniating
through a colostomy defect (arrow). Contrast is seen in the colostomy bag (arrowhead).
Image B is a coronal reconstruction and shows the herniated small bowel in the
subcutaneous tissues (arrow).
CT: computed tomography.
Graphic 91151 Version 3.0

Parastomal hernia
(A) An anterior view of a large paracolostomy hernia. Note the skin breakdown
in the peristomal area where the appliance would be placed. This commonly
occurs due to the pressure required to maintain the appliance in place against
a large parastomal hernia.
(B) A lateral view of a large paracolostomy hernia.
Courtesy of Robert Cima, MD.

Types of parastomal hernias
Four types of parastomal hernias:
(A) Subcutaneous - bulges into the subcutaneous tissue.
(B) Interstitial - burrows into a muscular plane.
(C) Peristomal - enters the space between layers of prolapsed bowel.
(D) Intrastomal - enters the plane between the emerging and the everted part
of the bowel forming the ostomy.

Surgical repair of parastomal hernia
Operative procedures used for repair of a parastomal hernia.
(A) Relocation of the stoma - high risk of failure.
(B) Direct repair of the fascial defect - high rate of recurrence.
(C) Subcutaneous mesh repair - low recurrence risk but undermining is a

risk for ischemic injury to skin.
(D) Extraperitoneal mesh repair - most common approach for repair with
lower failure rate.

Abdominal wall mesh placement
Options for placement of mesh in the abdominal wall:
(A) Onlay: mesh is placed anterior to the anterior rectus sheath.
(B) Sublay: mesh is placed immediately above the posterior rectus sheath.
(C) Intraperitoneal: mesh is placed directly beneath the peritoneum.

Intraperitoneal mesh repair of parastomal hernia
(A) An intraperitoneal Sugarbaker mesh repair.
(B) An intraperitoneal keyhole mesh repair.

Laparoscopic mesh repair of parastomal hernia
The parastomal hernia is repaired with mesh placed via the

laparoscope.
(A) The mesh is prepared for placement prior to insertion into the
abdominal cavity. Nonabsorbable sutures are placed on the edges of
the mesh to later secure to the abdominal wall. An incision is made in a
cruciate manner in the mesh to allow for a tension-free construction
and repair around the bowel.
(B) The mesh is rolled and applied to cover the defect.
(C) The mesh is secured to the abdominal wall and unrolled around the
bowel.
(D) The mesh is fully opened and sutured to the bowel as well as the
abdominal wall.

Contributor Disclosures
Robert R Cima, MD, MA, FACS, FASCRS No relevant financial relationship(s) with ineligible companies to
disclose. Michael Rosen, MD Employment: Medical Director of AHSQC (Americas Hernia Society Quality
Collaborative). Grant/Research/Clinical Trial Support: Intuitive Surgical [Inguinal hernia]; Pacira [Ventral
hernia repair]. Consultant/Advisory Boards: Artiste Medical [Mesh]. All of the relevant financial
relationships listed have been mitigated. Wenliang Chen, MD, PhD No relevant financial relationship(s)
with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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2022, 09:46 Parastomal hernia - UpToDate

Official reprint from UpToDate®

EPIDEMIOLOGY AND RISK FACTORS

● End ileostomy – 1.8 to 28.3 percent

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● End colostomy – 4.0 to 48.1 percent

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Acute complications — There is a low rate of life-threatening complications associated with

● Stoma appliance dysfunction and leakage not responsive to conservative measures.

● Recurrent partial bowel obstruction.

● Chronic abdominal pain related to the parastomal hernia.

● Psychological distress caused by any of the previous symptoms. The evaluation of

MESH FOR PARASTOMAL HERNIA REPAIR

Various types of mesh (polypropylene, expanded polytetrafluoroethylene [ePTFE], biologic) have

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Open versus laparoscopic repair — Reports of decreased patient morbidity and improved

Primary repair — Parastomal hernia repair was once performed in a manner similar to

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● Keyhole technique – In the keyhole technique, a 2 to 3 cm "keyhole" cut-out is made to

Laparoscopic approach — The technique of laparoscopic parastomal hernia repair has not

● Primary suture repair – 69.4 percent

● Onlay mesh – 17.2 percent

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● Sublay mesh – 6.9 percent

● Open, intraperitoneal mesh

• Sugarbaker - 11.6 percent

Recurrent parastomal hernia repair — Recurrent parastomal hernias present many

PERIOPERATIVE MORBIDITY AND MORTALITY

Perioperative mortality following elective repair of parastomal hernia using commonly

SOCIETY GUIDELINE LINKS

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SUMMARY AND RECOMMENDATIONS

● A parastomal hernia is a type of incisional hernia that allows protrusion of abdominal

● Patients with symptoms and signs of complicated bowel obstruction (complete,

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Use of UpToDate is subject to the Subscription and License Agreement.

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14. Serra-Aracil X, Bombardo-Junca J, Moreno-Matias J, et al. Randomized, controlled,

23. Hotouras A, Murphy J, Power N, et al. Radiological incidence of parastomal herniation in

29. Moreno-Matias J, Serra-Aracil X, Darnell-Martin A, et al. The prevalence of parastomal

32. López-Cano M, Lozoya-Trujillo R, Quiroga S, et al. Use of a prosthetic mesh to prevent

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CT: computed tomography.

Graphic 91151 Version 3.0

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(B) A lateral view of a large paracolostomy hernia.

Courtesy of Robert Cima, MD.

Graphic 76715 Version 4.0

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Types of parastomal hernias

Four types of parastomal hernias:

(A) Subcutaneous - bulges into the subcutaneous tissue.

(B) Interstitial - burrows into a muscular plane.

(C) Peristomal - enters the space between layers of prolapsed bowel.

Graphic 69519 Version 4.0

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Surgical repair of parastomal hernia