A hernia is a weakness or split in the muscle wall of the abdomen which allows the abdominal contents (usually some part of the intestine) to bulge out. The bulge is particularly noticeable upon tensing the abdominal wall muscles, such as occurs when coughing, sneezing or straining.
Stomas pose an additional problem.
When a stoma is brought out to the surface of the abdomen it must pass through the muscles of the abdominal wall, thus a potential site of weakness is immediately created. In the ideal situation the abdominal wall muscles form a snug fit around the stoma opening. However, sometimes the muscles come away from the edges of the stoma thus creating a hernia. In this case, an area of the abdominal wall adjacent to the stoma where there is no muscle.
Factors that can contribute to causing a stoma hernia to occur include coughing, being overweight or having developed an infection in the wound at the time the stoma was made. The development of a stoma hernia is often a gradual phenomenon, with the area next to the stoma stretching and becoming weaker with the passage of time. This weakness, or gap, means that every time one strains, coughs, sneezes or stands up, the area of the abdomen next to the stoma bulges, or the whole stoma itself protrudes as it is pushed forwards by the rest of the abdominal contents behind it.
As with all hernias the size will increase as time goes by. Stoma hernias are rarely painful, but are usually uncomfortable and can become extremely inconvenient.
They may make it difficult to attach a bag properly and sometimes their sheer size is an embarrassment as they can be seen beneath clothes. Although a rare complication, the intestine can sometimes become trapped or kinked within the hernia and become obstructed. Even more seriously the intestine may then lose its blood supply, know as strangulation. This is very painful and requires emergency surgery to untwist the intestine and prevent the strangulated part of the bowel from being irreversibly damaged. Regardless of inconvenience or pain, hernias are defects in the abdominal wall and should not be ignored simply because they might not hurt.
There are surgeons who advocate that small stoma hernias that are not causing any symptoms do not need any treatment. Furthermore, if they do need treatment it should not be by operation in the first instance but by wearing a wide, firm colostomy / ileostomy belt. This is probably true with small hernias in people who are very elderly and infirm or people for whom an anaesthetic would be dangerous (for example, serious heart or breathing problems).
We feel that nowadays operative repair of the stoma hernia should be given more serious consideration to improve the quality of life, prevent progressive enlargement of the hernia with time and make it easier to manage the stoma.
Repair of stoma hernias – The usual approach
If symptoms are severe enough, the hernia is repaired. The repair of a stoma hernia requires that the abdominal wall tissue is made to fit back snugly around the stoma, leaving no weakness. Over the years many different surgical approaches to this problem have been tried.
There are two options. One can move the stoma to a new site on the abdomen, i.e. create a new opening elsewhere and repair the hernia at the old site as one would any other hernia, or one can try to repair the hernia around the stoma, leaving the stoma where it is.
Repair of the hernia without moving the stoma involves opening the abdominal wall over the hernia adjacent to the stoma and re-suturing muscle and supporting tissues in the area.
Although this may appear to be the most straightforward way of doing it, this is not always a successful method.
If the original stoma site is unsatisfactory for other reasons, or if the hernia is very large, it may be necessary to re-site the stoma, making a new stoma through fresh, healthy tissue. The area of the hernia, together with the site of the original stoma is then repaired, usually by stitches.
This can be a more successful procedure regarding repair of the hernia, but is a more major operation because of the many technical, surgical difficulties in dismantling the existing stoma and transferring it from one side of the abdomen to the other.
A more modern approach
Whether one chooses to leave the stoma at its original site or to move it, we feel that the hernia itself should be repaired with mesh over and beyond the weakened area to reinforce the whole weakened muscle structure.
This is an improvement over the original stitching method and our technique usually enables us to avoid the more major procedure of re-siting the stoma.
Once inserted, the mesh rapidly becomes incorporated within the muscle and surrounding tissue and forms the core of a much stronger area within the abdominal wall. This is very similar to the way builders put a steel mesh inside reinforced concrete.
Although the mesh we use is wafer-thin and lightweight (yet extremely strong), the principle is the same, in that the mechanical load becomes spread over the whole area rather than pulling on any individual stitches through the muscles.
This use of mesh, rather than stitches, serves to avoid future recurrences, which happen when the stitches used with other methods are pulled away from the tissue.
Once the bowel is seen to function normally, our kind of mesh repair generally requires 1 or 2 days in hospital, following which a rapid recovery with a more reliable repair can be expected. Because the reinforcing effect of the mesh gives strength to the repair without the tissue distortion and tension of other methods, most patients are able to be completely mobile and engage in normal levels of exercise within a very few days.
Whilst there can be no guarantee of the permanence of any stoma hernia repair, it is felt that this technique offers the least risk of recurrence.
As this is a highly specialised area of surgery, one should take care to seek surgeons with the appropriate level of experience with hernias, and specifically stoma hernias and this technique of repair.