Surgical approach to parastomal hernias

Parastomal hernia is an incisional abdominal wall hernia that involves astoma. It is a common problem in patients with an intestinal stoma with anincidence of up to 50% or more.Patients with stomas are at the highest risk of herniation during theinitial 3-5 years after surgery, although hernia occurrence has been reportedas late as 20 years after stoma creation. Herniation usually develops lateral tothe stoma site.Once a parastomal hernia has been diagnosed, seventy percent of thepatients will be asymptomatic and can be managed nonoperatively. Typical reasons for surgical intervention include bowel obstruction, bowelstrangulation, bleeding, pain, and poor fit of the stoma appliance.Surgical therapy includes direct tissue repair of the defect, stomarelocation, and placement of a prosthetic mesh. Irrespective of technique,open repair is associated with high morbidity and non-mesh repair carries ahigh recurrence rate.For local tissue repair of parastomal hernias and stoma relocation,recurrence is seen in 46 to 100% and 76% respectively. When utilizingprosthetics, a keyhole mesh configuration and nonslit mesh repairs have beendescribed. Dr Sugarbaker first described the nonslit mesh repair in 1980; thistechnique has been most effective, with the lowest recurrence rate.The success of the Sugarbaker repair is attributed to the flap-valveaction of the mesh on the bowel as it exits the peritoneal cavity and entersthe abdominal wall. Minimally invasive approaches to parastomal herniarepair have gained popularity.Mancini et al. described their experience with a laparoscopic modifiedSugarbaker technique; patients were followed for 19 months and had arecurrence rate of 4%.A review of literature supports the use of minimally invasive approachwith prosthetic reinforcement as the optimal means of parastomal herniarepair.