Management Of Parastomal Hernias Research Articles

Hernia Support Garments for Parastomal Hernia Following Ostomy Procedure

What Is the Issue?
 
 Parastomal hernia is a common complication that can occur following ostomy surgery. They can have a negative impact on a person’s quality of life, affecting them both physically and psychologically. One intervention that may be used to help prevent or manage parastomal hernias are hernia support garments.
 To help inform decisions about the most appropriate use for hernia support garments, it is important to understand the current best practices as well as potential benefits and harms of using these garments.
 
 What Did We Do?
 
 We searched for clinical and cost-effectiveness literature comparing hernia support garments to alternative hernia prevention or management strategies or no intervention. We also searched for evidence-based guidelines that provide recommendations about the use of hernia support garments for the prevention or management of parastomal hernias.
 An information specialist searched for peer-reviewed and grey literature sources published between January 1, 2013, and November 1, 2023.
 We engaged with an individual who has lived experience of an ostomy and parastomal hernia and who wears a hernia belt regularly. He shared his thoughts on the physical and psychological benefits, impact on quality of life, and challenges of using a hernia belt. This gave CADTH a more nuanced understanding of the literature.
 
 What Did We Find?
 
 We did not find any studies directly evaluating the clinical or cost-effectiveness of hernia support garments versus alternative hernia prevention or management interventions or no treatment that met the inclusion criteria for this review.
 Three evidence-based guidelines made recommendations related to using hernia support garments to prevent and manage parastomal hernia. One guideline recommends that individuals with an ostomy should be assessed to determine the type and level of support required to prevent or manage hernia. Another guideline recommends that health providers provide postoperative education on using support garments. The third guideline recommends that stoma care nurses provide lifestyle advice about support garments to individuals with a stoma. This guideline also recommends that these nurses should be available to advise on non-operative management options for parastomal hernias more generally.
 
 What Does This Mean?
 
 Decision-makers might wish to consider ways to ensure that individuals who have had or are scheduled to have an ostomy surgery have timely access to parastomal hernia risk assessment, education, and advice on the use of hernia support garments from nurses specialized in wound, ostomy, and continence care. They may also want to consider out-of-pocket costs that may be a barrier to this care.

Preoperative Progressive Pneumoperitoneum Enables Defect Closure and Laparoscopic Repair of Large Parastomal Hernias.

Preoperative progressive pneumoperitoneum (PPP) has not been reported in the management of parastomal hernias; therefore, the present study evaluated its effectiveness in the surgical management of large parastomal hernias. This prospective, observational study included 23 consecutive patients with large parastomal hernias who underwent PPP between January 2016 and September 2018. The volume of parastomal hernia (VPH), volume of the abdominal cavity (VAC), and the VPH/VAC ratio were measured before and after PPP using abdominal computed tomography scan data. All the hernias were repaired by a laparoscopic or laparoscopic-open-laparoscopic approach using the intraperitoneal Sugarbaker technique. Before and after PPP, the mean VPH was 1442 and 1581 mL (P<0.01), and the mean VAC was 5667 and 9194 mL (P<0.01). The VAC increased by 3527 mL (P<0.01) and was greater than the mean VPH before PPP. The VPH/VAC ratio after PPP was reduced at an average of 8.1% (P<0.01). Fascial closure was achieved in all patients, with no clinical evidence of elevated intra-abdominal pressures. The mean follow-up was 24 months (13 to 40 mo), and, to date, no hernia recurrences have been reported in these patients. PPP is a feasible and useful tool in the surgical management of large parastomal hernias. It passively expands the abdominal volumes, thereby resulting in respiratory adaptation to elevated intra-abdominal pressures.

Expert Commentary on Diagnosis and Management of Parastomal Hernias.

Expert Commentary on Diagnosis and Management of Parastomal Hernias.

Prevention and treatment of parastomal hernia: a position statement on behalf of the Association of Coloproctology of Great Britain and Ireland.

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) Delphi process identified prevention and treatment of parastomal hernia (PSH) as the second highest priority non-cancer related colorectal pathology. This position statement aims to summarize the current evidence base. Four broad themes were identified (prevention, diagnosis/classification, management and operative repair). Guidelines are based on evidence from an extensive literature review using organized searches on the PubMed, MEDLINE, Embase and Cochrane databases. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adhered to for classifying the quality of evidence and reporting the strength of recommendations. The suture repair of PSH other than for patients in extremis is not recommended. Synthetic non-absorbable mesh can be used safely in the short term in the construction of colostomies post rectal surgery, but longer-term follow-up is needed. Other broad recommendations are made around access to stoma care nurses, prevention classification and management. There is a lack of high quality evidence for many domains in the prevention and treatment of PSH but the results of several studies are awaited. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Parastomal hernias are a common and debilitating condition following stoma formation. This position statement from ACPGBI details the current evidence base and ongoing research for the prevention, diagnosis and management of parastomal hernias.

Using a risk assessment tool for parastomal hernia prevention.

All patients with a stoma are at risk of developing some degree of parastomal herniation given enough follow-up time. Based on current evidence, preventive measures are strongly advised to minimise the incidence of a parastomal hernia forming. This article explores the evidence for consistency in care and management of parastomal hernia, focusing on the development of a risk assessment tool, taking into consideration the patient's and the nurse's perspective.

Nursing strategies for the prevention and management of parastomal hernias

Parastomal hernias, in which a section of bowel protrudes through the abdominal wall, are a common complication of stoma-forming surgery. This can cause a decrease in a person's quality of life, due to physical discomfort, a highly visible bulge and poor appliance adhesion, leading to leakage of the stoma appliance. Risk factors include the patient's age and health, as well as the physical properties of the stoma and how it was formed. The limited nursing research on the topic recommends that strengthening the abdominal wall by using exercises and support garments can dramatically reduce the incidence of herniation. Should a hernia occur, recommended management options include wearing a support garment or surgical repair, sometimes using a mesh, although hernias often recur after they have been repaired. It is important for stoma care nurses to advise patients how to prevent, as well as treat, this problem.

Indication for the surgical management of parastomal hernias.

Indication for the surgical management of parastomal hernias.

Assessing support garments in the management of parastomal hernia

Many ostomates (people with a stoma) are affected by the complication of a parastomal hernia. The ostomate does not only need to adjust to the stoma but also to the presence of the parastomal hernia and its effect on the stoma function, appliance choice, and skin condition; moreover, it affects the ostomate's ability to manage his/her daily activities. The NHS spends over £1 million in the provision of support garments. While this is a cheaper management option compared with surgery to repair or refashion the stoma, it is important that the most appropriate type of garment is chosen. Selecting the most appropriate garment not only ensures that the person with a stoma can manage the garment easily but also avoids costly trial and wastage of NHS resources. Having knowledge of the type and range of support garments available enables the nurse to advise and assist people in the management of parastomal hernias.

Prosthetics for Parastomal Hernia Repair

It is an accepted fact that parastomal hernias are a common and frustrating problem. Traditional surgical techniques of direct fascial repair and stoma relocation have largely fallen out of favor because of their poor outcomes. Synthetic prosthetic grafts have long been used in the repair of other types of hernias. Despite their known risk factors, including infection and erosion into bowel, they have been used extensively in the surgical management of parastomal hernias. Recently, newer bioprosthetic materials are beginning to make an appearance in clinical trials with promising results. Placement of these prosthetics in the sublay or underlay positioning is associated with the best outcomes. Lastly, the technique of routing the bowel is a hotly debated point—whether routing should be done through the prosthetic (keyhole technique) or around the prosthetic (Sugarbaker technique). The majority of published studies have used the keyhole technique with a wide range of success rates. Recently, the Sugarbaker technique is gaining in popularity with promising early results.

Laparoscopic parastomal hernia repair using a nonslit mesh technique

The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes. A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence. A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence. On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

Evaluation and Management of Parastomal Hernia in Association with Continent Urinary Diversion

Evaluation and Management of Parastomal Hernia in Association with Continent Urinary Diversion

Evaluation and Management of Parastomal Hernia in Association with Continent Urinary Diversion

Purpose We discuss the incidence and diagnosis of parastomal hernias in association with continent urinary reservoirs. We also present a surgical technique appropriate for correction of this complication. Materials and Methods We evaluated 21 patients with parastomal hernia after construction of a continent urinary reservoir. The hernia developed secondary to diversion with an ileocecal segment in 19 patients and a Kock procedure in 2. Subsequent to development of the parastomal hernia 13 patients (61.9%) had simultaneous urinary incontinence, 2 (9.5%) had difficulty catheterizing the reservoir and 4 (19.047%) had associated pain over the stomal area. Evaluation was primarily by physical examination. However, 2 patients (9.5%) required abdominal computerized tomography to confirm the diagnosis of parastomal hernia. Surgical repair was recommended for all patients, and 19 underwent repair with or without revision of the anti-incontinence segment. Reconstruction included transabdominal takedown of the anti-incontinence segment from the abdominal wall with parastomal hernia closure through a midline incision, external reinforcement of the hernia opening with Marlex mesh when the diameter exceeded 6 cm., revision of the anti-incontinence mechanism when simultaneous urinary incontinence existed preoperatively and repositioning of the stoma site through a new selected area in the abdominal wall. Results The success rate (mean followup 23.4 months) with this surgical approach was 89.5%. Incontinence due to failure of the anti-incontinence mechanism was successfully corrected in 13 patients (100%). Conclusions Long-term followup of continent urinary reservoirs is often associated with development of parastomal hernia. This complication can be associated with urinary incontinence, peristomal pain and difficult catheterization. Evaluation is primarily by physical examination but selected clinical situations require abdominal computerized tomography to confirm the diagnosis. The surgical technique following the steps described has been associated with minimal morbidity and has provided excellent surgical results (89.5% success rate).