Key principles
• Risk factors and optimization as per per Incisional Hernia Repair • Patient selection is Key • Consideration of the need for Stoma o Can it simply be reversed • Consideration of repair of current site, or re-siting required
I would repair a parastomal hernia after careful and thorough assessment of the patient and hernia anatomy, aiming to reverse the stoma where possible, consider re-siting or repair the hernia defect with similar principles to an incisional hernia by suing a mesh repair technique in either a sublay or intraperitoneal position.
Specific preoperative preparation
• Define anatomy • Determine patient sx and need for repair • Determine if stoma can be reversed o If so, confirm that the original reason it was done no longer exists (eg check distal anastomoses) • Mark secondary stoma site
Operation Details
• There are several options o Stoma reversal - My preferred approach if at all possible o Stoma re-siting - Usually to contralateral side - Second preferred option as avoids mesh complications, but hernia risk at new site still exists o Direct primary repair - High recurrence rate o Mesh repair - Onlay • Less recurrence than primary repair, but increased mesh complications -Sublay • Reduced mesh complications and recurrence, but difficult dissection in the required plane - Intraperitoneal • Keyhole → Mesh around stoma trephine • Sugarbaker → Mesh over opening internally and bowel passes out lateral border • This can be done as either an open or laparoscopic approach • Key steps o Supine position o Incision depends on approach and operation o Mesh used → Lightweight, synthetic +/- Composite
Post-operative complications
• Immediate o Intra-op - Bleeding - Visceral injury - Anaesthetic complications • Early o Infection o Bleeding o Seroma • Late o Recurrence o Mesh complications - Erosion - Infection - Stoma obstruction secondary to fibrosis etc