STOMAL HERNIA

WHAT IS A STOMAL HERNIA?

Stomal or para-stomal hernias as they are probably better described occur through the opening in the abdominal wall used to create a stoma either ileostomy or colostomy. In a sense they are a type of incisional hernia. Because a hole is created in the abdominal wall to form the stoma there is a potential weak spot for a hernia to develop. They can occur soon after an operation or may develop months or years later. Stomal hernias are quite common and when small may go unnoticed. Stomal hernias left untreated can get larger with time.

Why do some people get stomal hernia?

In some cases we simply don't know but we are aware of certain risk factors. Stomal hernias are more common after emergency abdominal surgery. Other factors that can lead to hernias are:

  • Excessive coughing or straining after an operation
  • Increasing age
  • Steroids
  • Obesity
  • Smoking

HOW CAN YOU PREVENT GETTING A STOMAL HERNIA?

In some cases you simply can’t, but you can reduce the risk or help prevent an existing hernia getting larger by:

  • avoiding heavy lifting wherever possible
  • using your legs and not your back to lift heavy objects if you need to
  • avoiding constipating or straining during bowel movements
  • maintaining a healthy weight
  • stopping smoking

TREATMENT

For small hernias that are not causing any symptoms a surgical repair may not be necessary. All surgery carries the risk of complication so for some patients watchful waiting is advised.

A different sort of stoma bag with convexity can help with small hernias, as can a simple elasticated stoma belt. A colorectal nurse specialist should be able to advise you on this. A hernia belt may be beneficial for some patients with a hernia who do not want an operation. These can provide additional support to the abdominal wall. The belt is worn over the hernia site to prevent it coming out. These belts are usually made-to-measure by a specialised appliance fitter. More modern elasticated support garments may provide an alternative for those who wish to avoid surgery or wear a belt but there isn’t any good evidence that they will prevent hernias enlarging.

A hernia repair is usually advised if a hernia becomes symptomatic i.e. starts enlarging causing discomfort, or generally interfering with the activities of daily living or starts causing problems with bag fitting. Stomal hernias can vary in size from very small to very large and no single operation is suitable for all types of hernia. Your surgeon will discuss which are the best options open to you.

The operations can be done as open or as keyhole procedures, again not all stomal hernias are suitable for a keyhole repair. Hernias are repaired using sutures or a combination of sutures and a mesh reinforcement. Generally sutured repairs are only suitable for smaller hernias and large hernias nearly always need a mesh reinforcement as well. The principle of the repair is to place the hernia back in the abdomen and to narrow the opening in the abdominal wall to prevent it recurring. Its important to make the opening tight enough to prevent that but not to make it so tight that it interferes with stoma function. Sometimes when a stomal hernia is vey large or has been repaired previously the surgeon may advise moving it to a different site on your abdomen, usually on the opposite side. All para-stomal hernia repairs are carried out under a general anaesthetic.

Open sutured repairs are usually carried by cutting around the stoma itself. The surgeon finds the hernia and pushes it back inside the abdomen before narrowing down the opening in the abdominal wall with strong stitches. This is the simplest type of repair and can be usually carried out as a day case procedure. This type of repair is probably associated with a higher risk of recurrence but the risks associated with infection are less.
Open mesh repairs usually involve making an incision away from the stoma itself and tunneling under the skin and fat around the stoma. The hernia can then be put back into the abdomen and sutures used to narrow the defect before it is reinforced by a piece of mesh placed around the stoma. A drain may be placed close to the repair to prevent fluid accumulating. Patients will need to stay in hospital at least overnight and sometimes longer. This type of repair is probably associated with a lower risk of recurrence but the risks associated with infection are greater and the mesh itself can sometimes cause problems.
Keyhole repair may be possible for some stomal hernias. A number of small incisions are made in the abdominal wall. The hernia is identified and pulled back into the abdomen. The opening around the stoma is then reinforced with a mesh that is held in place on the inside of the abdominal wall with tacks. This type of repair may be performed as a day case procedure. It may not be possible to carry out a keyhole procedure particularly if there are lots of adhesions from a previous operation. Overall this is a more invasive approach. This type of repair is probably associated with a lower risks of recurrence, compared with open sutured techniques and a lower risk of infection, compared with the open mesh technique. The mesh itself can cause problems if it is too tight.

WHAT ARE THE RISKS OF THE OPERATION?

Sometimes bruising may occur around the wound(s) or a swelling develop beneath the wound(s). This is usually blood and / or tissue fluids which accumulates in the space where the hernia was. The fluid will normally gradually resolve.

Wound infections can occur after this type of surgery. When they do occur patients may need a course of antibiotics. This is particularly important if a mesh has been used. With bad infections sometimes a re-operation is required and the mesh may need to be removed.

You should contact your doctor if after the operation you develop any of the following:

  • redness around or drainage from the incision(s)
  • fever
  • bleeding from the incision(s)
  • pain that is not relieved by medication or pain that suddenly worsens

Particularly when an open mesh repair has been carried out a collection of fluid can collect in the space once occupied by the hernia. This is known as a seroma.

Small seromas can safely be left alone and many will disappear completely over time. Sometimes these fluid swellings can grow quite large and tense. In this case the collection of fluid may need to be drained off with a needle.

Some patients particularly men can find it difficult to pass urine after a hernia repair. It is always important to tell your surgeon, before coming in to hospital, if you are experiencing any difficulties passing urine. Occasionally a catheter may need to be passed if a patient is unable to pass urine and if that is necessary patients usually will have to stay overnight before the catheter can be removed the next day.

A few patients may continue to experience pain in a hernia wound that does not settle down straightaway. We think that this may occur if a nerve is trapped in the mesh material a suture or the scar. Sometimes a local anaesthetic and steroid injection will relieve symptoms. It is very rare that a wound need be re-explored because of pain.

A number of people may develop a recurrence of the hernia.

RECOVERY

We encourage all patients to stay active following surgery. Walking regularly is the most useful exercise after the operation. Following the operation you should avoid heavy lifting for 4-6 weeks. After about 4 weeks you should be able to increase your exercise activities. Starting with gentle rhythmic exercises such as cycling or cross-training and gradually building up to your normal exercise regimen. Provided there are no wound problems swimming can also be good at this stage.

You should be able to return to work within one or two weeks but if your job involves any strenuous activities you may need to be off work for longer or carry out only light duties.

It is difficult to be specific about driving as this will be dependant on the site and size of the hernia repaired. After repair of a small hernia some patients can usually drive again after one to two weeks but this may be four weeks or more for larger hernias. Your surgeon will give you specific instructions regarding this.