Parastomal Hernias
Question:
My doctor says I have a hernia around my stoma. What do I need to know about this?
Answer:
Simply, a hernia is an abnormal protrusion, or out-pouching, of bowel through a weakened area in the abdominal wall (the abdominal wall being the muscle and fat layers). In the case of a hernia around the stoma, the weakened area is where the stoma comes through the abdominal wall. Depending upon how large that weakened area is and how much bowel protrudes through, you may notice only a slight bulge of your abdomen around your stoma, to a significant large protrusion that is noticeable even under clothes. There are several things you should know about the hernia and how to manage it.
A hernia around the stoma (parastomal hernia) occurs in about 5-10% of people with colostomies, and about 3-10% of people with ileostomies. While it is difficult to predict who will develop a parastomal hernia, certain factors are known to predispose someone to its development:
- Site of the stoma: ideally, when a new stoma is made, it should be brought through a muscle in the abdomen called the rectus abdominus. Placement of the stoma outside of this muscle (more over to the side of the abdomen) can lead to a hernia around the stoma.
- Obesity: people who are obese may develop parastomal hernias more readily than those of normal weight.
- Malnutrition: poor nutrition around the time of the stoma surgery may delay normal healing, and result in a weakness in the abdominal wall.
- Age: poor abdominal muscle tone with advancing age may result in eventual herniation.
- Increased intra-abdominal pressure: increased pressure within the abdomen, which can occur with severe or chronic coughing, severe sneezing, or lifting heavy objects, may weaken the abdominal muscle around the stoma, leading to a hernia.
- Infection after stoma surgery: this may, again, weaken the abdominal muscle and result in a parastomal hernia.
Parastomal hernias may develop soon after surgery, or may take years to develop. Most people (about 80%) will not experience any difficulties with the hernia and will not require any intervention. The remaining 20%, however, may have symptoms that require some help to manage. Some hernias will correct themselves with different positions: you may find that your hernia is only noticeable when you are standing or sitting, and may “disappear” when you are lying on your back. Sometimes the hernia is noticeable regardless of your position.
A parastomal hernia may cause some abdominal discomfort. People can describe a sense of fullness or tightness, or a heavy weight to the parastomal area that is not painful, but uncomfortable. Supporting the hernia with a special elastic hernia belt or with a lycra type undergarment may provide enough support to eliminate that feeling. Belts need to be measured or sized to appropriately fit your abdomen, and to ensure correct placement of an opening within the belt that allows for the ostomy appliance to come through. If you are having severe pain related to your stoma or hernia, you must seek immediate medical attention. An Enterostomal Therapy (ET) nurse can help you to decide if a belt or lycra undergarment is an option to help manage your hernia.
A parastomal hernia may also change the size and shape of your stoma. You may even find that the size and shape of your stoma changes when you are standing/sitting, and again when you are lying flat. These changes may cause more frequents leaks of your appliances, or may cause peristomal skin irritation. If the hernia is large, you may also find that you can no longer see your stoma to adequately care for it. If this occurs, you should contact your ET to review pouching options with you, and you should also see your surgeon to discuss options for surgical repair of the hernia.
Some people find that a parastomal hernia changes their stoma function and bowel habits. The hernia can cause the stoma to not function as often or even to cramp when it tries to function; it may cause abdominal distension (or bloating). Discussion with your surgeon should occur if you are experiencing these symptoms, as surgery may be indicated. More seriously, you may find that the hernia prevents the stoma from functioning. You must immediately seek medical attention if this occurs. People who have a colostomy and a parastomal hernia, and who manage their stoma with irrigations may need to consider stopping irrigations all together. Irrigations may worsen symptoms and cause further complications. You can consult your ET to discuss conversion to a regular pouching system.
Some people simply dislike the appearance of the hernia and want to have it surgically corrected. You should discuss with your surgeon whether repair of the hernia is an option for you. Different approaches can be taken to repair the hernia, including a local repair right at the stoma site, or resiting the stoma to the other side of the abdomen and closing the hernia. Your surgeon will be able to discuss with you if surgery is indicated, and the risks and benefits of the different types of repairs.